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Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).


Patient Information

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( for Text Message Reminders )

Bill To Contact

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Log in Details

( If patient is a minor, the legal guardian must enter their email address below. )

Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment.

A full fee of is charged for missed appointments or no show cancellations with less than a 24 hour notice unless due to illness or an emergency. A bill will be mailed directly to all clients who do not show up for or cancel an appointment.

Thank you for your consideration regarding this important matter.
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Prescription refills
Prescription refills should be requested during your office visit.

Suboxone prescription refills are ONLY done during your office visit. Please do not call at the last minute requesting a refill for Suboxone.
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Contents of all therapy sessions are considered to be confidential. Both verbal
information and written records about a client cannot be shared with another party
without the written consent of the client or the client's legal guardian. Noted exceptions
are as follows:

Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health
professional is required to warn the intended victim and report this information to legal
authorities. In cases in which the client discloses or implies a plan for suicide, the health care
professional is required to notify legal authorities and make reasonable attempts to
notify the family of the client.

Abuse of Children and Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has
recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of
abuse, the mental health professional is required to report this information to the appropriate
social service and/or legal authorities.

Prenatal Exposure to Controlled Substances
Mental Health care professionals are required to report admitted prenatal exposure to
controlled substances that are potentially harmful.

Parents or legal guardians of non-emancipated minor clients have the right to access the
clients' records.

Insurance Providers (when applicable)
Insurance companies and other third-party payers are given information that they request
regarding services to clients.

Information that may be requested includes type of services, dates/times of services,
diagnosis, treatment plan, and description of impairment, progress of therapy, case notes,
and summaries.

I agree to the above limits of confidentiality and understand their meanings and
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