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 18 years old )
( MM-DD-YYYY )


( optional )
( optional )





( 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




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

Cancellation, Rescheduled, or Missed Appointments Policy
You are responsible for attending each appointment and agree to adhere to the following policy:
If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment at least 24 hours prior to the scheduled appointment time. If you cancel or reschedule within the 24 hour period, you will be charged the full session rate.  If you miss a scheduled appointment or are more than 20 minutes late the appointment will be cancelled and you will also be charged the full session rate.  Cancelling and rescheduling your appointment within the 24 hour period, or missing your appointment can deny other clients the opportunity to schedule or reschedule into that time slot. If you cancel, reschedule, or miss more than three sessions, we may re-evaluate your needs, desires, and motivations for treatment at this time.
( Type Full Name )
( Full Name )
Telehealth Policy

Teletherapy sessions will not be held while operating a vehicle. If you need to be in a vehicle during your session, please ensure that before the session starts, you are parked in a place where you feel safe and comfortable. If at the start of the session, I notice that you are operating a motor vehicle, the session will be canceled and a late cancellation fee will be charged. 

Teletherapy sessions will not be held while in a public space. If you need to be in a public space, please ensure that before the session starts, you find an area that is private, safe, and comfortable for confidentiality reasons. If you cannot get to a private area, the session will be canceled and a late cancellation fee will be charged.
( Type Full Name )
( Full Name )