Therapy Waitlist Intake Form
Thank you for your interest in our services! Please complete this form to join a therapy waitlist for one of our clinicians who currently have full caseloads. We will contact you as soon as an opening becomes available.

This form takes approximately 5 minutes to complete.

If you would prefer to answer these questions verbally on the phone with one of our clinic coordinators, give us a call at (437) 783-5210‬. Please leave us a voicemail with your availability for a callback, and a member of our administrative team will return your call to gather the information needed to add you to the waitlist. Thank you!
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Full Name *
Email Address *
Phone Number *
Pronouns 
Age
Preferred method of contact  *
Required
What service are you interested in? *
Required
  Are you looking for:   *
General Availability
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
How often are you hoping to meet with your therapist?
Clear selection
  Are you hoping to work with a specific clinician?  
If you answered Yes, which clinician? 
Are there things that matter to you about a clinician's style or approach? (e.g. Do you prefer a structured approach, or a more client-directed approach? A solution-focused approach or a more exploratory approach? Homework or no homework?...)
In a few words, what are you hoping to get out of therapy? What are you hoping to work on? (E.g., specific tools or strategies, renewed self-understanding, etc.) *
If your preferred clinician is unavailable for an extended period, would you like us to:  
Clear selection
What themes are you primarily looking to address in therapy?
Is there anything else you would like us to know?

How did you hear about Accord Psychology?

Sometimes we may need a little more information to determine whether one of our clinicians would be a good fit. Are you comfortable with us contacting you if we have follow-up questions?   *
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