Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

How did you find out about me? *

Google/internet search

IFS Institute Directory

Recommendation/word of mouth

Other

How often do you hope to attend sessions? *

(Most clients begin with weekly sessions.)

Weekly

Every other week

Other

How do you intend to pay? *

(My fee is $160/session. See the Services page for more information on fees and payment.)

Private pay/out of pocket (via Zelle or credit card)

File for out-of-network insurance reimbursement

I’d like to be considered for equity pricing