G.E.M. Therapy LLC | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Date of birth

Gabrielle can only work with clients that currently reside in Wisconsin or Florida. Which state do you live in?

Wisconsin Florida

How did you find me?

Can I text you via HIPAA compliant phone system to connect about setting up a consult?

Yes No

Message

Please share a brief summary of what brings you to therapy, Days/Times you are hoping to have therapy sessions, and best way to reach you (Phone, Text, E-mail). If you are eligible for Lyra Health Benefits and plan to use them, please indicate this here - Thank you!

Limited to 600 characters

Billing & Payment

My submission of this form verifies that I am aware of the following:

I am aware of Gabrielle's fees: $225 for initial assessment for individual therapy and $200 for follow up individual sessions; $250 for initial assessment for couples therapy and $225 for follow up couples sessions. Gabrielle does not accept insurance and that I am responsible for paying the full fee at time of service.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.