Self Pay Options

Name *

First Name

Last Name

Phone *

(###)

###

####

What type of appointment are you interested in? *

Select all that apply.

In-Clinic

Virtual

Which days do you prefer for sessions? *

Select all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day do you prefer? *

Select all that apply

Mornings

Afternoons

Your information will be used solely to respond to your inquiry and coordinate care. This form is not a secure, HIPAA-compliant platform. Please avoid submitting sensitive medical details. *

I understand this form is not a secure HIPAA-compliant platform and agree not to submit sensitive health information.