Name *

First Name

Last Name

Phone *

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Insurance & Cost: I am an out-of-network (OON) provider and am not paneled with insurance, but I do provide superbills upon request. My current rate for a 55-minute individual session is $200. *

I understand

Privacy Disclaimer: I acknowledge that electronic communication, including web forms and email, is limited in terms of privacy and may be intercepted by a third party. I understand that this electronic communication does not constitute a therapeutic relationship. By submitting this form, I hereby release Adora Du and Spring Day Therapy PLLC from any and all liability that may occur due to electronic communication over a non-secure network. *

I understand