Name *

First Name

Last Name

Phone *

(###)

###

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Preferred Contact Method? *

Email

Phone

I am aware that I must reside in Ohio or New York in order to receive services:

Yes- I am aware and meet this criteria

I acknowledge that Allie currently only accepts Aetna insurance (all other clients are subject to regular session fee of $200 per session) *

Yes- I am aware of the fee/insurance accepted