Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Full registration prior to appointment for all attending requires the completion of the following: Policy, HIPPA, Technology consents, Personal History, Credit Card to hold appt. The info must be completed within 48 hrs to confirm the appt date & time discussed by phone. Please allow 20 mins to thoroughly complete this process. If do not fully complete the forms prior to session then your session cannot begin as scheduled and you may use session time to complete it.

Client Type

Client Information

/ Middle Initial

( optional )
 

( MM-DD-YYYY )


( optional )
( optional )







(optional) (required)
( for Text Message Reminders )

Bill To Contact


/ Middle Initial







Emergency Contact


First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )