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
Date
Referred By / How did you find me?
*
Main Concern
*
Your Availability
*
Dates, Days and/or Times that work for you (on Mon, Tues, Wed or Sat)
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
*
$175 per (50 minute) individual or couples session
4 sessions at $150 per (50 minute) session
Initial consultation $75 (25 minutes) or $150 (50 minutes)
Brainspotting for trauma resolution (90 minutes) - $250
Health Insurance (Cigna, United, Optum, Multiplan)- Enter insurance & policy# below
Name of Insurance & Policy Number (and/or EAP Authorization)
Submit
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