NAME *

First Name

Last Name

PHONE *

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###

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PREFERRED CONTACT METHOD *

Call

Email

APPOINTMENT YOU'RE REQUESTING *

Individual Therapy

Group Therapy

Couple's Therapy

Psychiatric Medication Management

Psychiatric Medication Management Consult (this is for women who already have a provider, but want a second opinion on their current medications)

Somatic Embodiment (Yoga, Breathwork, Meditative Healing, & Sacred Self Love)

Empowerment Session with Heather Land, M.C.L.C.

Other

HOW DID YOU HEAR ABOUT US? *

Provider Referral

Friend

Psychology Today

Instagram

Facebook

Google

TikTok

Other

PRIVATE PAY PRACTICE ACKNOWLEDGMENT *

We are a private pay practice and DO NOT ACCEPT INSURANCE, but we’re happy to provide a superbill to submit to your insurance company for reimbursement. We DO accept HSA or FSA cards.

I have read and agree this acknowledgment.

CONTACT CONSENT AND ACKNOWLEDGMENT *

I consent to be contacted through the email address and phone number that I have provided. I accept that a member of the SHEchiatry team will call me, leave a voicemail, and send follow-up email.

I have read and agree to this acknowledgment.