Appointment request form
Beth McWhorter, MA LPC LLC requires prospective new clients to provide the information below prior to an initial appointment being scheduled. Thank you.
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Email *
Full Name *
DOB (Required for insurance) *
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DD
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Phone number including area code *
Availability for appointments *
Please describe your availability for appointment days and times (Monday - Friday).
Insurance company *
Complete insurance information is necessary to schedule first appointment. Your actual insurance card must be presented at the first appointment. Photos or photocopies are insufficient.
Amount of Insurance Deductible and Co-pay *
Please contact your insurance company's customer service phone number (found on the back of your insurance card) to obtain this information.
Employee Assistance Program (EAP) Clients Additional Information
Please fill out the additional fields below if you are a clients using your employer provided EAP benefit.
Name of Employer providing EAP benefit
EAP Provider
Example: Espyr, Ulliance, etc.
EAP Authorization number  
Call your EAP for this information.
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