Name *

First Name

Last Name

Phone *

(###)

###

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What services are you interested in? *

Couples or individual therapy, 50-minute sessions

Couples or individual therapy, extended intensive sessions

Couples or individual therapy intensive for 1-3 full days

Payment for Therapy *

I understand that Latalia is not in network with any insurance companies and will not submit any information or paperwork to insurance companies. I understand that I am fully responsible for all services and payment at the time of service.

I understand