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Discovery Call Application Form

What state do you live?

What is your main reason for requesting a Discovery Call?

What does wellness look like to you?

What would be your ideal outcome from working with me?

To confirm a call, I require a credit card to hold a time spot for you on my schedule. You will not be charged unless you miss the appointment. A $75 fee will be charged for missed appointments or cancelations less than 24 hrs. in advanced. Do you agree with this policy?

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What services are you interested in?

I accept some insurance for covered services. All other patients pay with credit card, HSA, FSA. How would you plan to pay for your services?

Is there any other information that you'd like me to have while I review your application?

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