Booking at Emotions In Harmony

1

Have you had an appointment with us before?* This field is required.

No, this is the first time I am scheduling

Yes, I have already registered

2

Legal Name* This field is required.

First Name

Last Name

3

Chosen Name* This field is required.

First Name

Last Name

4

Gender* This field is required.Example: Man / Non-Binary / Transgender / Woman

5

Date of Birth* This field is required.

Date

6

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Phone Number* This field is required.

Area Code

Phone Number

8

E-mail* This field is required.

example@example.com

Confirm Email

9

How did you hear about us?* This field is required.

10

Through what other method did you hear about us?* This field is required.

11

Do you want to book the appointment by yourself?* This field is required.

Yes

No, please contact me

12

In which language would you like to have your session?* This field is required.

English

Spanish

Both are fine for me

13

Therapy Modality* This field is required.

In Person

Online

Both are fine for me

14

Type of Service* This field is required.

Individual Therapy

Couples Therapy

Family Therapy

Immigration Evaluation

15

Your psychologist is ready to serve you!* This field is required.

Dr. Carmen Román

16

Which psychologist do you prefer? Both are ready to serve you!* This field is required.

Dr. Liz Caine

Dr. Carmen Román

Please assign me one

17