Name *

First Name

Last Name

Date of Birth

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DD

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Phone Number *

By entering your phone number you are agreeing to receive phone calls and voicemail messages at this number.

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Preferred Method of Communication

Email

Phone

I am licensed in Pennsylvania and an approved telehealth provider in Delaware and Vermont, so services must be rendered within one of these three states. Are you a resident of Pennsylvania, Delaware or Vermont? *

Yes

No

I am an out-of-network provider, meaning that I do not accept any insurance and clients pay me directly for sessions. For more information, please visit the FAQ section of my website. Please click the box below to acknowledge that you understand that I am not in-network with any insurance providers. *

Yes, I understand that you are not in-network with any insurance providers