Waitlist For Therapy With Emily Cooper
Hi! Thanks for your interest in receiving therapy from me! Please fill out the form below and I will be in contact with you when I have openings. 

Thanks!
Sign in to Google to save your progress. Learn more
Name (first and last) *
Phone number *
Email address *
Reason for seeking treatment? *
Is it ok to text the number above? *
Is it ok to email the email address above? *
I do not take insurance, however I am able to provide you with a receipt if you'd like to seek reimbursement on your own. (Read the "pricing" section of my website for information on how to know how much they'll give you back.)

The initial consultation sessions is $200 and subsequent sessions are $150. Please confirm you have read and understand this.
*
I am only able to meet with clients who are current residents of Utah. Please confirm this applies to you. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy