If interested, please provide your
Full Legal Name: Preferred name (if applicable):

Date of Birth: Phone Number:

Address where you live: Insurance Information:

IMPORTANT NOTE: Only in network with most Community Care plans and Lyra. (Indicate in your message if you prefer to opt out of using insurance.)

Once I have all the information we need to get you in the system, I’ll send you 2 emails. The first will be from my work email and has additional information on the practice, how to complete one specific form so we can bill, and how to schedule appointments once we’ve got you established. The second email will be from Therapy Appointment. This is our portal to complete documentation and schedule appointments. We cannot schedule any appointments until the documentation is complete.