Consultation Form

Name *

First Name

Last Name

Phone *

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Type of Service

Individual Therapy

Couples Therapy

Sex Therapy

Consultation Agreement *

I understand this is a complimentary 15-minute consultation and does not guarantee treatment. I also understand that in order to receive treatment I must reside in Wyoming, Maryland, Virginia or the District of Columbia. Lastly, I understand that the provider is Out-of-Network and will not accept insurance as a form of payment.

Yes, I understand and agree