Name *

First Name

Last Name

Phone *

(###)

###

####

Select Desired Clinician *

Illamí (Mimi) Romero Martínez-King

Ashlee Fowler

Nora Abbou

Mary Elliott

Myshia Liles-Moultrie

Kelly Koerner

Any Available

Telehealth Consent *

I fully understand that all sessions will be fully virtual through a HIPPA compliant platform provided by the clinician. No in-person sessions will be conducted.

Yes, I am aware all sessions will be conducted virtually

SMS Message Opt-In *

I consent to receive SMS message from Holistic Vida Therapy, LLC

I do not consent to receive SMS message from Holistic Vida Therapy, LLC