Name *

First Name

Last Name

Phone *

(###)

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DeeAnnah can only work with clients that currently reside in North Carolina. Please confirm state residence below. *

Yes, I live in North Carolina.

My submission of this form verifies that I am aware of the following *

I am aware of DeeAnnah's fees: $175 for initial assessment for individual therapy and $150 for follow up sessions; $200 for couples and family sessions.

I am aware that if DeeAnnah does not accept my insurance provider that I am responsible for paying the full fee at time of service. Superbill receipt will be provided per request.

I am aware that submission of this form does not constitute a client-therapist relationship and that the information I'm sending is not encrypted.