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Secure Scheduling Form
Please complete this multi-page form to schedule your first session.
Your First Name
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Your Last Name
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Your Pronouns
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Your Email Address
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Your Phone Number
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Please acknowledge that emails and text messages should not contain sensitive information.
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I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.
Are you over 18 years of age?
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Yes
No
Do you plan to pay for your sessions at least partially with out-of-network insurance?
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Yes, I plan to pay at least partially with out-of-network insurance
No, I plan to pay fully out of pocket and/or with an employer benefit or don't know
What is the name of your employer?
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