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).

Please complete all forms and enter the credit card you would like to pay with. Cards will be billed at the end of day on date of service.

Patient Information

Legal First Name / Middle Initial

Last Name

Preferred First Name ( optional )

Date of Birth
( MM-DD-YYYY )

Gender
Male Female Transgender Non-binary

Pronouns ( optional )

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 #

Bill To Contact

Same as above Different

First Name or Organization Name / Middle Initial

Last Name

Street Address

Street Address 2

City

State

ZIP Code

Phone

Emergency Contact

First Name

Last Name

Phone

Mobile

Relation

Street Address

City

State

ZIP Code

Log in Details

( If patient 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. )

Evolving Self Psychological Services LLC - Secure Patient Area

Register

Patient Information

Bill To Contact

Emergency Contact

Log in Details

Challenge Questions