Appointment Request

Thank you for your interest in working with me.

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Name

First

Last

Phone Number

Your City and State

Are you interested in:

Telehealth
In person, in Tempe, Arizona
A combination of Telehealth and In person.

Preferred Day and Time

I am 18 years of age or older.

I am seeking services for myself and not someone else.

interested Are each

I understand this is a direct pay practice that does not accept payment from any insurance companies

My rate is currently $200 for an initial 50 minute session and $200 for each 50 minute follow up session. Initially, we may meet once a week for the first few weeks, then meet every other week, depending on your needs and goals. Are you able to commit both financially and time-wise to this arrangement?

Yes, I am ready and able to make this investment in my wellness.
No, not at this time. I’ll check back with you if that changes.

Yes, I want to submit this form.

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking “yes, I want to submit this form” you agree to hold Taana Abbitt and The Awakened Heart harmless for unauthorized use, disclosure, or access to your protected health information sent via this electronic means.