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Appointment Request
While I cannot give an exact timeline for appointment openings, this list will be consulted first when I am able to take on new clients
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email Address
*
Your answer
Phone Number
*
Your answer
May we text the number given?
*
Yes
No
Parent/Guardian Name (if under 18yo)
Your answer
Parent Guardian Phone Number
Your answer
May we text the parent number given?
Yes
No
Clear selection
What kind of services are you needing?
Individual
ADHD Coaching
Supervision
Other:
Clear selection
What insurance would you be using, if any?
*
BCBS
UHC/Optum
Ambetter
SAS
Lockard & Williams
Tricare
Aetna
No insurance/Self-pay
Other:
What have you been experiencing that led to you seek services?
*
Anxiety
Depression
Mood Swings
Inattention/Poor Focus
Low Self-Esteem
Obsessive Perfectionism
Post-Grad Supervision
Other:
Required
May we contact you via email to share other referral resources in addition to being added to the waitlist?
*
Yes
No
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