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Please fill out below and then click "submit." I will receive the form electronically. You will receive an email acknowledging receipt.  This form will be kept confidential and stored with your insurance information and therapy notes. 

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

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