My Therapy Network - Online Application

Call 1.800.XXX.XXXX

Call us NOW at 800.XXX.XXXX to talk with a licensed therapist from your state.

To subscribe online using our secure website, please provide the following information.

Your personal information is being collected for the purpose of credit card billing only. My Therapy Network understands the sensitivity of its services and clients. We will never share or sell any information about you with any other persons, websites or companies for any reason whatsoever.

Please Note: Subscribers must be over the age of 18. My Therapy Network does not presently provide services to individuals under the age of 18.

Last Name:
Middle Initial:
First Name:
Address 1:
Address 2:
City:
State:
Zipcode:
Day Phone: (Optional)	No dashes or spaces
Evening Phone: (Optional)	No dashes or spaces
E-mail Address:	(To subscribe to our free monthly E-Newsletter.)
You must fill out the following payment information completely for your application to be processed. Click here for pricing schedule. You will be charged only when you have been successfully connected and have completed your call with the therapist.
Credit Card:
Cardholder's Name (FirstName, MI, LastName):
Credit Card #:	No dashes or spaces
Expiration Date:	MMYY MM=Month YY=Year May, 2001. Entered as: 0501
Billing Address Zipcode:
You must fill out the following Security information completely for your application to be processed:
Please choose a 10-digit access code.	(Suggestion: any telephone number with area code.) If the number is not accepted, please choose another number. No dashes or spaces
Security PIN (4-digits):	No dashes or spaces
Confirm Security PIN:	No dashes or spaces
Question we should ask if you forget your Access Code and/or Security PIN:	(Suggestions: mother's maiden name, pet's name; high school; favorite sports team, etc.)
Answer to above question:
This answer authorizes My Therapy Network LLC to release your Access Code and PIN to the caller.

After you have submitted your application, please wait for confirmation of your Access Code and Security PIN. Then call our toll-free number, 800.873.7100 and follow the voice prompts to speak with a therapist.

If you have questions about subscribing or would like other information about My Therapy Network, please call Customer Service at 800.XXX.XXXX.

* Credit card required at time of subscriber registration. Click here for pricing schedule.

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