Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

All forms must be properly and fully completed BEFORE an appointment is established.

The Clinical Assessment Form is only completed for persons using their medical insurance who can demonstrate medically necessary symptoms that need to be addressed in counseling. If you are interested in couples counseling or family counseling, please simply mark N/A in the forms and my services will be fee for service ($200.00 per session) as insurance companies do not pay for couples counseling.

Client Type

Client Information

Legal First Name / Middle Initial

Last Name

Preferred First Name ( optional )

Date of Birth ( Must be at least 18 years old )
( MM-DD-YYYY )

Street Address

Street Address 2

City

State

ZIP Code

How did you find me?

Cell Phone ( for Text Message Reminders )
Preferred Contact #

Home Phone
Preferred Contact #

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )

Confirm Email

Username
Between 8 and 40 letters and numbers

Local Time / Timezone

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

Question #1

Answer

Question #2

Answer

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Cancellation Policy

Fees and Cancellation: The fee for each session is $200.00 and is paid at the time of the visit. Once an appointment is established, you are responsible for the time you have reserved. If you need to reschedule, you may do so without paying for the session if the rescheduled time is within 24 hours of the appointment. If you provide 24 hour notice no charge will be assessed to your account. If you do not provide 24 hour notice a charge of $200.00 will be assessed to your account because you purchased the time. This allows Dr. Semon the opportunity to make the time available to other clients who may be attempting to schedule. You acknowledge and authorize me to bill your credit card or debit card for missed appointment times.

Electronic Signature of Client or Legal Guardian ( Type Full Name )
( Full Name )
I have read and I agree to the Cancellation Policy

Confidentiality

Confidentiality: Privileged Communication is any communication between a client and Dr. Semon, given in confidence and not intended to be disclosed to a third party other than those to whom disclosure is made in the furtherance of providing professional services to the client. Confidentiality does not include: Child abuse of any kind; Threat of physical harm to yourself or another person; a Court Order may result in release of records and/or testimony; When conducting marriage or family counseling, information is not kept from the other spouse or family members in the course of counseling.