Untamed Therapy & Consulting

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

Describe briefly what is bringing you to therapy or any questions you have.

Limited to 600 characters

Type of Session Requesting (Office is located in Cape Coral, FL)

In-Person Telehealth

Note: You must be located in Florida for duration of therapy services

I confirm I am located in Florida

Which therapy service are you interested in

55-minute sessions | Weekly or Bi-weekly ($185) EMDR Therapy Intensive | 2-4 HR Package or Program (starting at $1,375)

Untamed Therapy & Consulting is an OUT-OF-NETWORK provider.

This means you pay for services upfront and if your insurance plan includes out-of-network benefits, we'll help you submit for reimbursement through a service called Thrizer.

I understand that Untamed Therapy does not accept insurance

Administrative

How did you hear about Untamed Therapy?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.