New Patient Appointment Request Form (2026)
Thank you for your interest in the Jacob Center! Please fill out our "New Patient Appointment Request Form" below if you are interested in treatment. 

Dr. Marni Jacob currently has a WAIT-LIST OF APPROXIMATELY 4-5 MONTHS for treatment.

Dr. Luis Ordaz currently has limited new patient openings via TELEHEALTH.

*If you have flexibility in scheduling or provider, treatment can often start sooner.
*Afterschool timeslots are in highest demand, and there is often a longer wait to start treatment for higher-demand times. 

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.
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 by reviewing our Frequently Asked Questions, which includes answers to commonly asked questions, accessible at: https://www.jacobcenterforebt.com/faqs.html

Please pursue referrals if you are in urgent need of care. 

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

Sign in to Google to save your progress. Learn more
Name of Patient
Today's Date (not Date of Birth)
MM
/
DD
/
YYYY
Age of Patient
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 to discuss availability/scheduling. We encourage you to add our email address to your contacts (info@jacobcenterforebt.com) to ensure receipt.
Brief description of presenting problem/concerns:
Please indicate which providers you would be interested in seeing (you may select multiple options). All of our providers have specialized training in OCD, Anxiety Disorders, O-C Spectrum Disorders, & Phobias. 

Please click this link to learn about our providers: https://www.jacobcenterforebt.com/providers

Current Provider Fees:

D. Luis Ordaz, Ph.D., Licensed Psychologist
· Intake Evaluation (up to 90 minutes): $325
· Standard Session (50 minutes): $250

Marni L. Jacob, Ph.D., ABPP, Board-Certified, Licensed Psychologist 
· Intake Evaluation (up to 90 minutes): $450
· Standard Session (50 minutes): $350

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. Be as specific as possible (e.g., anytime; 9-12pm; after 2pm) to help with scheduling. We do not currently offer sessions on weekends.
Do you prefer sessions via telehealth, in-person, or it  doesn't matter? 
- Due to high demand, there will be a longer wait for in-person sessions after 3pm.
*Note: Telehealth can only be provided when you are physically in the state of Florida, or if you are located in an approved PsyPact state, due to Psychology licensing laws https://psypact.org/mpage/psypactmap
Clear selection
Who were you referred by? If self-referred, please indicate so (or how you found out about us).
Please indicate any additional notes, or list any questions we can answer for you.
Please confirm that you are aware that our practice is self-pay, and we 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.
Please confirm awareness that there is a waitlist of 4-5 months for new patients with Dr. Jacob. 
Dr. Ordaz has sooner availability.
*Please pursue referrals if you are in urgent need of care.
Clear selection
Thank you for completing our new patient request form! 

We will be in touch via email within 1 week to confirm receipt of your inquiry, or if we have any questions. To ensure you receive our email, please add the following email contacts/address book (since our emails may go to SPAM): 

info@jacobcenterforebt.com

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. We can also be reached by phone at (561) 290-9080.                                                 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of jacobcenterforebt.com.

Does this form look suspicious? Report

Google Forms