New Client Appointment Request
By entering your full name, email address, insurance information and phone number below, you are providing personal information that will be used by Larneka Lavalais, LPC
 PLLC for the sole purpose of responding to your request. We will only use this information to contact you to schedule your appointment.
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Email *
I agree I am not in danger at this time and would like to request an appointment.

 *
If you are in serious or foreseeable danger, please call 911 or go to the nearest hospital.
***Please note: All appointments are virtual at this time.***
Client Type *
Service Type *
Client First and Last Name *
Parent/Guardian Name (Minor only)
Client Email (For minor add Parent/Guardian Email) *
Phone Number *
Home Address *
Are you using insurance? *
Insurance Accepted
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🛑 PLEASE NOTE: If using EAP, it Is helpful to provide us both your EAP (to use initially) + your insurance information to use after conclusion of EAP, so we can verify the benefits and inform you of your copay in a timely manner. Please upload to Client Portal when link is provided.
Availability for sessions. You are welcomed to select multiple slots of availability *
Required
Provider Accepting New Clients Listed Below Insurance or Cash pay *
A copy of your responses will be emailed to the address you provided.
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