Your Name *

First Name

Last Name

Phone *

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Patient's Name *

First Name

Last Name

Is the Patient a minor or an adult? *

Minor (Under the age of 18 years)

Adult (18 years or older)

Method of Payment *

We do not accept insurance. Payment is due at the time of service. If you have a PPO plan we will provide you with a superbill to request reimbursement from your insurance provider.

Out of Network Benefits (PPO Plans only)

Direct Pay/Out-of-Pocket

How did you hear about us? *

Psychiatrist/Nurse Practitioner

Pediatrician

Primary Care Physician

Teacher/Tutor

School Psychologist/School Counselor

Community Clinician (OT, SLP)

Previous Client (Referral from a friend)

Self-Referred (e.g., Website, Google)