Want to schedule an Appointment? Good Faith EstimateOut-of-Network Provider Policy Legal Name * First Name Last Name Preferred Name/Pronouns: Phone * (###) ### #### Upon agreeing to giving us your phone number, the following is noted: * I agree. Email * What's bringing you to therapy? * This is only reviewed by the therapist and the office administrator. If you would like to just let the therapist know directly, please put "n/a". Do you need to inquire about reduced rate services? * Yes, I need more information. No, not at this time. Are you interested in scheduling a 15 minute consultation with Dori before scheduling? * Yes - please contact me for setting this up. No - I would like to just schedule an appointment. Can you give me more information of what this is and then decide? Cancellation Fee/Credit Card Policy: * I understand by sending this inquiry, if I am to establish services with Dori that I will be subject to putting down a valid credit card number to hold my appointment. Alchemy of the Mind has a 24 hour cancellation policy and the card will be charged the according fee for the service if notice. In the event of an emergency and needing to cancel, please let our staff know. I agree. Insurance * I understand that Alchemy of the Mind does NOT accept insurance at this time, but can provide me with a superbill for potential (not guaranteed) reimbursement from my insurance. I agree. Thank you! I will get back to you within 72 business hours. If you need assistance sooner, please call or text 303-916-5235.
