Synergos Counseling & Nutrition Waiting List
To request a consultation/appointment, please complete the form below or call our office. If we have available sessions with providers, we will call and/or email you. If not, you will NOT receive a call or email and rather be added to our waitlist and receive a call in the future when we have availability to schedule you. You are always welcome to call our office to get an updated wait time. You will receive a confirmation after you have submitted this form for your own records.

If your insurance is not listed in the question below about insurance, then we are considered out of network and are able to provide you with a "superbill" to submit directly to your insurance. Please ALWAYS verify that your health plan includes dietary benefits as well if seeking those services. Some plans have many exclusions defining requirements for use of those benefits.

We are offering HIPAA compliant telehealth services as well as some limited in-person options. If using telehealth, please check with your insurance to assure you have telehealth benefits. Additionally, we require that you have access to both video and audio features in a secure location when participating in telehealth as this is most often required by your insurance for reimbursement. We are unable to do sessions while you are in your vehicle traveling.
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Email *
Full Name of Potential Client (first and last name) *
If the client is under the age of 18 and you are filling this form out for them, please indicate your full name and relationship to the potential client.
Telephone Number (a message may be left at this number) *
Preferred email, if different than the one used above to complete this form
Client's Date of Birth (Month/Day/Year) *
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