Contact You can go straight to my Headway page to book a consultation, or submit this form and I will get back to you ASAP. This form is not HIPAA-compliant. Keep this in mind when submitting personal health information (PHI). * Ok, got it. Name * First Name Last Name Phone * (###) ### #### Email * Please ONLY submit this form if you are genuinely interested in getting started and want to see if we are a great fit/really want to learn more. ***I set aside time to respond to you and save a spot for your genuine interest in getting started! * Got it! Yes, I am motivated and genuinely interested in getting started. What is your motivation, 1 out of 5 (5 being highly motivated) to get started, get relief, and make progress? * 1 (Not Motivated) 2 3 4 5 (Highly Motivated) How did you hear about us? * Google Facebook Instagram Word of Mouth Other We accept both out-of-pocket payments and are able to bill some insurance companies. If you'd like to use insurance, please list your provider below. * Confirm by typing "I understand" and provide insurance carrier if applicable: What challenges are you currently facing that you'd like to overcome? * How do you picture your life/business/health/etc. changing after we work together? * How committed are you to making progress in the areas you named above? * Would you like us to reach out to you by texting you or by emailing you? * Text me! Email me (make sure to check your junk mail as well, within the next 24 business hours) Text and email me, please! If you selected to be “texted” above, please type the phone number you want us to text you at OR put “N/A”: * Thank you for filling out this form, we will get back to you in less than 24 business hours! Please make sure to check your junk mail. * Ok, got it! Thank you!
