Request for New Patient Appointment
*Clinicians at the Jacob Center for Evidence-Based Treatment are NOT currently accepting new patients. However, we are happy to notify when we have availability.

If you are interested in becoming a new patient, please complete the New Patient Request Form below. We will then email you to notify you when we have availability. We do not anticipate that this will be before 1-2 months, so please pursue referrals if you are in urgent need of care. Scheduling varies based on clinician availability, as well as patient flexibility in scheduling.

If you have questions about our practice, we encourage you to email us at info@jacobcenterforebt.com.

We also encourage you to check out our Frequently Asked Questions, which includes answers to commonly asked questions, accessible at: https://www.jacobcenterforebt.com/faqs.html

Please note that we specialize in treatment of OCD, O-C Spectrum Disorders, Anxiety Disorders, & Phobias. Due to the specialized nature of our practice, we are self-pay and do not take any insurance directly, although we'd be happy to provide you with documentation to help you submit for out-of-network benefits. More information about this can be found at the above link to our FAQ's.
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Name of Patient
Birth Date
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YYYY
Age of Patient
Today's Date / Date of Inquiry
MM
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DD
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YYYY
Sex of Patient
Clear selection
Parent(s) Name: (if applicable)
Best Contact Phone Number (for Parent if patient is under 18). *If a parent is calling for a patient who is over age 18, you may list contact numbers for both a parent and the patient.
Best days/times to reach you by phone?
Email Address for Patient (if patient is over 18) or for Parent (if patient is under 18), if you would like for us to contact you via email.
Please check the below box to give consent for us to email you when have availability for new patients.
Who were you referred by? If self-referred, please indicate so (or how you found out about us).
Brief description of presenting problem/concerns:
Please indicate which providers you would be interested in seeing? (You may select multiple options). Please click this link to learn about our providers: https://www.jacobcenterforebt.com/providers
Session Availability (Weekdays/Times). If completely flexible, please indicate so. *Note: Given that we see a large number of children & adolescents in our practice, after-school times tend to be most in-demand. We do not currently offer sessions on weekends.
Please indicate any additional notes, or list any questions we can answer for you.
Thank you for completing our new patient request form! We will be in touch when we have availability, or if we have any questions. If you have any questions for us, we can also be reached via email at info@jacobcenterforebt.com, as that is the quickest way to get in touch with us.                                                                                                                                                                                                                                                  
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