Appointment Request
Please complete this form to request appointment. Make sure to go through each page and hit submit.
Email *
First and Last Name *
Email *
Address *
Phone number *
Information about Person Needing Services
Please complete the following information about the person who is needing services.
First Name *
Middle Name *
Last Name *
Perferred Name *
Date of Birth of individual seeking services *
MM
/
DD
/
YYYY
Sex Assigned at Birth *
Pronoun Preference
Marital Status *
Ethnicity (Check All That Apply) *
Required
Please describe why you are seeking services *
Email *
Phone Number *
Preferred Contact Method *
Required
Physical Address *
City *
State *
Zip Code *
Emergency Contact/Parent and Guardian Information
Please complete the sections below that apply to your situation. If self referral complete the emergency contact information. Anyone under 18 needs Parent/Guardian Information Submitted.
Emergency Contact Information
First and Last Name *
Relationship *
Contact Phone Number *
Parent/Guardian 1
Please Enter Parent/Guardian Information for anyone under the age of 18. If over 18 ignore this section.
Please Select Which Situation Applies to You
Clear selection
First and Last Name
Relationship to Individual Needing Services
Physical Address
City
State
ZIP Code
Contact Number
Parent/Guardian 2
Please enter if under 18 and has a 2nd Parent/Guardian. 
First and Last Name
Relationship to Individual Seeking Service
Physical Address
City
State
ZIP Code
Contact Phone Number
Preferences and Scheduling Times
Please complete below for available times and Therapist Preferences.
*
8am-9am
9am-10am
10am-11am
11am-12pm
12pm-1pm
1pm-2pm
2pm-3pm
3pm-4pm
4pm-5pm
5pm-6pm
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred Gender of Therapist
Clear selection
1st Choice Therapist *
2nd Choice Therapist *
What Insurance Do you Have? *
Do you have secondary Insurance?
Clear selection
What is the name and Date of Birth of your plan's Policy Holder?
This will be the person whose name is on your insurance card. If you do not have Private Insurance, type "N/A"
 *
What is your Group Number and Member ID?

Please specify which number is which, as not all plans look the same. If you do not have Private Insurance, type "N/A"
 *
If an EAP, what is the EAP name, authorization number, and how many sessions are covered? *
If you are using an EAP, Please be sure to include your insurance information as well. If you do not have an EAP, put "N/A"
 *
Submit
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