New Client Appointment

Dr. Tani Psychological Services for Children, Adolescents & Young Adults

Your Name

Last Name

Email address

Phone Number

I am requesting a new appointment for:

Myself My Child

Age of Prospective Client

Child's First Name

Child's Last Name

Your Date of Birth

Child's Date of Birth

I am the child's biological parent and/or legal guardian

Parents are currently:

Married Separated Divorced Together and never married Other

Please describe:

Are there any custody-related legal proceedings in progress or planned?

Yes No

In case of separated, divorced, divorcing, or never-married parents, both parents' signed consent would be required for Dr. Tani to be able to work directly with the child. Alternatively, you may upload a copy of the custody agreement or divorce decree indicating that you as the parent have custody over and/or can provide consent to psychological services.

If you, as your child's legal guardian, have custody over and/or can provide consent to psychological services, please upload a copy of the most current and valid custody agreement and/or divorce decree below

Add file

Please upload a file

I am interested in (other):

Generally, I can be available for appointments at 9:00 AM most:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Generally, I can be available for appointments at 10:00 AM most:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Generally, I can be available for appointments at 11:00 AM most:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Generally, I can be available for appointments at 12:00 PM most:

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Please know that Dr. Tani's practice is self-pay only. While Dr. Tani does not contract with insurance companies, upon request she provides clients an itemized receipt (also known as a 'superbill') that they may directly submit to their insurance company for any possible reimbursement.

Current rates: Initial session: $200 (60 minutes); Subsequent session: $185 (50 minutes)

Please describe your concerns / reason for appointment request:

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