Name *

First Name

Last Name

Phone

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Private Pay Disclosure *

Please check to indicate that you understand that I don't take insurance and that my fee is $265 per 50 minute individual session. I am able to submit an itemized receipt for you to submit to your insurance for Out of Network partial reimbursement.

Schedule Disclosure *

Please check to confirm that you understand that I offer therapy on a weekly basis or more frequently, and do not schedule less often than that.