Name *

First Name

Last Name

Phone

(###)

###

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Please review the following and mark each checkbox to confirm your understanding. *

I am licensed to practice in California and can only work with people located in CA.

Sessions are generally available Monday through Thursday from 12 pm to 6 pm.

I only work with adult clients (no minors).

You are able to pay my current full fee of $210 per 50-minute session and commit to a regular weekly time slot.

I am an out-of-network provider and do not accept insurance.

You are not suicidal or experiencing a mental health crisis.