Name *

First Name

Last Name

Phone *

(###)

###

####

What kind of appointment would you like? *

Initial counseling session

15 minute consultation (meet-and-greet)

Insurance & Fees *

I have reviewed the page about insurance and fees and understand that Lis is an in-network provider with only some insurance companies. If mine is not one listed, I understand that I will be expected to pay for services at the time they occur and will be provided with a monthly superbill for services that I can submit to my insurance company if I choose to seek reimbursement.

Yes