This form is not HIPAA-compliant. Keep this in mind when submitting personal health information (PHI). I am a cash only private practice and do not accept any insurance. *

Ok, got it.

Name *

First Name

Last Name

Phone *

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Please ONLY submit this form if you are genuinely interested in getting started and want to see if we are a great fit/really want to learn more. *

Got it! Yes, I am motivated and genuinely interested in getting started.

I am an out-of-pocket practice and DO NOT ACCEPT insurances. If you need to use insurance I am not the right fit for you. *

Yes, cash payment works for me.

No, this doesn't work for me. Please ignore my submission.

If you are in crisis, do not leave me a message here. Instead, call 988 or go to your nearest emergency room. I am not able to provide emergency services. *

I am not in crisis. I agree to call 988 or go to the nearest emergency room if a crisis emerges. I understand you don't provide emergency services.

Thank you for filling out this form, we will get back to you in less than 48 business hours! Please make sure to check your junk mail. *

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