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 )
 
( Must be at least 15 years old )
( 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

Updated financial informed consent agreement

Payment Policy: Credit Card Processing Fees. 

To offset rising credit card processing fees, a 3% surcharge will apply to all payments made by credit/debit/hsa cards. This fee is not greater than the cost to process the transaction. 

You may avoid this fee by choosing one of the following payment methods:

Cash

Personal check

Bank transfer (e.g.,ACH, Zelle)

If you have any concerns or financial limitations, please don't hesitate to discuss them with me. I am committed to ensuring that therapy remains accessible.

( Type Full Name )
( Full Name )