Request an Appointment

Appointment Form Simple

First Name of Person Requesting Appointment

Last Name of Person Requesting Appointment

Email Contact

Phone/Mobile

Age

This appointment is for:

Child’s First Name

Child’s Last Name

Child’s Age

Preferred Location

Briefly, tell us how we can help you?

You will be asked for a credit card to hold your appointment. You will be charged using this card for your appointment if it is not kept.

Please note we do not accept insurance.

Our appointment fee is $150 per 50 minute session. (Exceptions are senior level therapists, Terri Hallman $175.00 and Jill Smith 250.00)

We can happily give you a superbill for possible insurance reimbursement.

I have read the above and consent to hold my appointment