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 charged the full session rate.  If you miss a scheduled appointment, 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 )