Let’s Connect! Name * First Name Last Name Email * Phone * (###) ### #### May I text you at this number? * Yes No Please tell me how I can help you? * What goals would you like to work on together? * Your Age? 17-25 26-34 35-43 44-52 53-61 62-70 71+ City & State * I am a self-pay practitioner and do not accept health insurance. However, I provide the necessary documentation for you to submit claims to your insurance company for out-of-network services. * Yes, I understand that all services are self-pay. Thank you! Fill out the form below, and I’ll reach out to you soon. Let’s work together!