Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Please complete all forms for client, unless otherwise directed. When prompted for insurance information, please attach a copy of the policy holders ID and the insurance card.

Therapist

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )


( optional )
( optional )





( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Cancellation Policy

Any cancellation or rescheduling of an appointment must be done at least 48 hours prior to your appointment by calling and leaving a voicemail message with the office. Failure to cancel with at least 48 hours notice will require that you personally pay the full fee of $150 for the missed session . It is important for you to understand that your therapist has set aside your appointment time for you and cannot simply do other work if you are unable to attend. Fees for missed sessions are never paid by insurance companies and therefore you will be responsible for the payment for any missed appointments.

( Type Full Name )
( Full Name )