Enter how you were referred to our services
Do not upload sensitive financial information such as credit card information.
By submitting this form, you understand that the fee for a private-pay initial 50-minute intake session is $175 and payment is due at the time of service.
By submitting this form, I acknowledge that I am not enrolled in Medicare and understand that services cannot be provided on a private-pay basis if I am enrolled in this insurance program.
For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.