Request for New Patient Appointment
*Clinicians at the Jacob Center for Evidence-Based Treatment are currently accepting new patients. If you are interested in becoming a new patient, please complete the new patient request form below. At this time, we expect to schedule new patients within 1-month, which may vary based on clinician availability, as well as patient flexibility in scheduling.
Note: Dr. Marni Jacob will be going on maternity leave in June 2021 for approximately 6-8 weeks. Accordingly, she will not be taking new patients again until late Fall 2021. However, other clinicians at the Jacob Center have the same specialization as Dr. Jacob, and they are currently taking new patients.
We also encourage you to check out our Frequently 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.
Name of Patient
Your answer
Today's Date
MM
/
DD
/
YYYY
Age of Patient
Your answer
Sex of Patient
Female
Male
Prefer not to say
Other:
Clear selection
Parent(s) Name: (if applicable)
Your answer
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.
Your answer
Best days/times to reach you by phone?
Your answer
Email Address for Patient (if patient is over 18) or for Parent (if patient is under 18).
Your answer
Who were you referred by? If self-referred, please indicate so (or how you found out about us).
Your answer
Brief description of presenting problem/concerns:
Your answer
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
Dr. Jamie Sherman, Ph.D.
Dr. Luis Ordaz, Ph.D.
Dr. Marni Jacob, Ph.D., ABPP (No current availability, as Dr. Jacob will be going on maternity leave in June 2021. She expects to begin seeing new patients again in late Fall 2021. She has a wait-list for new patients to start around that time).
Any clinician - first available.
Session Availability (Weekdays/Times). If completely flexible, please indicate so.
Your answer
Please indicate any additional notes, or list any questions we can answer for you.
Your answer
Thank you for completing our new patient request form! We will be in touch when we have availability, or if we have any questions. We can also be reached via email at info@jacobcenterforebt.com
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