New Client Inquiry- Contact Form
Please fill out this short contact form and I will email you to set up a brief phone consultation or provide referrals to other therapists. Your needs are important to me; however, I ask that you please allow at least 1 week for reply to this inquiry.
How did you find out about my services?
Name of Person Completing Form
Name of Client
Very briefly, please describe your reason for seeking services. If you prefer not to say, please indicate that.
Date of Birth of CLIENT
BCBS (any state)
SAS/ First Choice
Lockard and Williams
United Medicaid (please verify that your insurance card says "United")
United Behavioral Health Commercial
State of Mississippi Medicaid (this is uncommon so please verify on your card)
Other- please list
Insurance Policy ID Number
Your personal phone number
Where are you located?
Do you require appointments after 3pm?
Which day of the week is your preference for the intake appointment?
No preference, first available.
Can you attend appointments at the Ocean Springs location?
A copy of your responses will be emailed to the address you provided.
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