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).

Please complete as much of the registration information and forms as you can before our first appointment. Choose the label that fits your interest (Individual Adult, Adolescent, Child, Couples, KAP, etc). If you would like me to consult with anyone else about your health and our services, complete a Release of Info form available within the forms section. This registration will help us utilize our first session to connect and create helpful goals for our work together.

Client Type

Client Information

/ Middle Initial

( optional )
 

( 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

( 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. )