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Therapist Matching Form

Date of Birth
Year
Month
Day
How did you hear about us?
Preferred method of communication (can select multiple)
Preferred appointment times
Preferred appointment days
Prefer to meet with my therapists
Have a therapist in mind? Select below

Fees


Our individual therapy services are fee for service. Ranging from $120-$150 per session. We currently cannot direct bill but we can provide you a receipt for you to submit to your insurance.

If you are needing services on a sliding scale, please write that in the box below & we can touch base about our sliding scale program.

Consent


By clicking submit, you are consenting to the gathering of personal information to Empowerment Health & Wellness, as well as consenting to receiving communication with your information listed. We will never sell or share your information.

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