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
Meeting Options (check all that you are interested in)
*
Face to Face Online
Phone Session
Fee Options for Online & Phone Sessions
*
$150 per (50 minute) session
4 sessions at $100 per (50 minute) session
Sliding scale $85 - $140 per (50 minute) session based on need
Initial consultation $50 (25 minutes) or $100 (50 minutes)
Health Insurance
Name of Insurance & Policy Number
Submit
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