Request An Appointment

Your Email (Person filling out this form)*

example@example.com

Full Name*

First NameLast Name

Your Phone (Person Filling Out This Form)*

Please enter a valid phone number.

How did you hear about us?*

Please provide the name of the professional/organization that sent us your way so we can thank them. 🎉

Don't worry...we won't reveal any information about you in our thank you.

Which service(s) are you interested in? (Click all that apply)*

Group Therapy ($15-65/hour)Individual ($135-$185/hr)MS Candidate ($25-50/hr)Couples*Family Therapy ($145-$200/hr)EMDR Intensive (starting at $995)EMDR Intensive Retreat (starting at $2495)

Which group are you interested in?*

Chronic Pain/Illness Support Group

Who needs the appointment?*

MyselfCouple/FamilyI am making a referral for my minor childI am a professional making a referral for someone elseI am a friend/family member making a referral for someone else

Please list the name(s) of whoever would be receiving treatment below.

Which therapist(s) are you interested in?*

Which locations work for you?*

Is there anything you would like to share?

HFTJ does not accept insurance, but does offer superbills for Out Of Network insurance reimbursement and has limited sliding scale & payment plan options.

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