Make an Appointment

Please complete this form to inquire about an initial appointment.

Financial Info

All session are $150. I accept cash, checks, HSA and all major credit cards.

Insurance Info

I am not in-network with insurance companies. I can provide you with a receipt of services that you can submit to your insurance company for possible out of network benefits (you’ll need to explore this option with your insurance company directly).

Name

First Name

Last Name

Phone

(###)

###

####

I understand this practice does not take insurance and that available sessions are $150 for 50 minute appointments.

Yes, I understand

I understand this practice does not work with couples and only works with singles or one partner in a relationship.

Yes, I understand

Describe in a few sentences the problems you're having aligning with love in relationships or dating?