Contact

Employment information is needed for new clientele that do not have solid provider references.  Please fill out the form below, so I am able to verify you as quickly and discreetly as possible! Please Note: A $200 surcharge is added to sessions booked with less than 24 hours notice to cover rushed screening.

Your Information

 

Employment Information

 

Provider Reference #1

 

Provider Reference #2

 

P411 Verification

 

Appointment Details

 

Verification

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