JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Send Us a Message
Getting in touch is easy! Send us a message here.
**This form is for prospective clients' enquiries only. Current clients to please use the client portal to send us a secure message.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone number
Your answer
What services do you need? Check all that apply.
*
Virtual Session
In-Person Session
After-Hours / Weekend
Individual Therapy
Couples Therapy
Accelerated Resolution Therapy® (ART)
Rapid Transformational Therapy® (RTT) Hypnotherapy
Other:
Required
Are you paying privately or using your out-of-network benefits?
*
Out of network (superbill will be provided upon your request)
We do not accept Medicaid or Medicare (unable to issue superbill for Medicare; opted-out of Medicare since 9/1/2024).
I am paying privately / self-pay.
I am using my out-of-network benefits.
Other:
Required
Message (Optional)
Your answer
Thank you for reaching out. We will get back to you as soon as possible.
If this is an emergency, call 911, go to your nearest emergency room, or call 988 for The 988 Suicide and Crisis Lifeline.
Submit
Clear form
Never submit passwords through Google Forms.
Forms
This form was created inside of Oneness Practice LLC.
Report Abuse
Terms of Service
Privacy Policy
Help and feedback
Contact form owner
Help Forms improve
Report