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).

Client Information

Legal First Name / Middle Initial

Last Name

Preferred First Name ( optional )

Date of Birth ( Must be at least 21 yearsz old )
( MM-DD-YYYY )

Gender
Male Female Transgender Non-binary

Pronouns ( optional )

Gender Identity ( optional )

Country

Street Address

Street Address 2

City

State

ZIP Code

Cell Phone ( for Text Message Reminders )
Preferred Contact #

Home Phone
Preferred Contact #

Emergency Contact

Country

First Name

Last Name

Phone

Mobile

Relation

Street Address

City

State

ZIP Code

Log in Details

Confirm Email

Username
Between 8 and 40 letters and numbers

Local Time / Timezone

Challenge Questions

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

Question #1

Answer

Question #2

Answer

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

Terms and Policy

Cancellation Policy

I have the utmost respect for your time and busy schedule and I ask the same in return. Appointment times are reserved just for you. If you miss your appointment or do not cancel with 24 hours notice, you will be required to pay the full cost of the treatment, as booked.

Electronic Signature of Client or Legal Guardian ( Type Full Name )
( Full Name )
I have read and I agree to the Cancellation Policy

Office Fees

All fees are due prior to the start of each session. No balances will be carried. In the event that a balance should occur, further sessions will be placed on hold until the balance is paid and a $10 late fee applied. Billing services are not available.

Fees may be paid through your secure client portal, and this is the preferred method. However, you may also pay in the office with a credit card, check or cash. Fees are collected at the beginning of each session.

Fees are $175 for a 60-minute in-office or online session and $250 for an 90-minute in-office or online session. Fees for workshops and seminars vary.