Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )






( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Payments

All payments must be submitted prior to the session start time. Payments can be made in advance for your convenience. Insurance payments are not accepted at this time. 

( Type Full Name )
( Full Name )
Cancellation

Please make cancellations through the client portal 48 hours in advance. If you have less than 48 hours please contact the therapist confidential cell phone via text or voicemail. Please be sure to leave you appt date and time if your cancelling by text as I want to protect your privacy and not ask for you your name in a text message. Please note that late cancellations may be subject to a cancellation fee. 

( Type Full Name )
( Full Name )