Name *

First Name

Last Name

Phone *

(###)

###

####

Please Read: Acknowledgment of Out-Of-Network Status *

Please check this box indicating that you understand we do not accept insurance. Our fees range from $225-$245 depending on the length of visit. Clients pay us up front for session fees and then they can independently submit to their insurance company for out-of-network reimbursement if they have out-of-network benefits. For more information regarding your out-of-network benefits please check with your insurance.