Shermin Davis Appointment Request Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Zipcode
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referred By / How did you find me?
*
Main Concern
*
Your Availability
*
Dates, Days and/or Times that work for you (on Mon, Tues or Wed)
Meeting Options (check all that you are interested in)
*
Face to Face Online
Phone Session
Brainspotting for Trauma Resolution (Online)
Fee Options for Online & Phone Sessions
*
$200 per (50 minute) individual or couples session
4 sessions at $175 per (50 minute) session
Initial consultation $100 (25 minutes) or $175 (50 minutes)
Health Insurance (United, Optum, Multiplan) - Enter insurance name & policy # below
Name of Insurance & Policy Number (and/or EAP Authorization)
Submit
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