Name *

First Name

Last Name

Phone *

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I understand that: *

Therapy services may not covered by my insurance and that I am responsible for finding out about my OON benefits. Payment is due at the time of service.

*

My sessions will be videotaped. Please read about how this informs your treatment on my specialty page on Deliberate Practice and Feedback Informed Treatment.

*

My therapist can only practice within the states of WA or UT and I will be located in one of those states at the time of service.