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Appointment Request
Please complete this form to request an appointment with Pond of Peace Counseling and Wellness; someone will be in contact with you within 3 business days. Please note that Pond of Peace is a TELEHEALTH ONLY practice and all sessions are conducted by Google Meet.
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Name
*
Your answer
Phone number
*
Your answer
Do you prefer to be contacted by email or telephone call?
*
Email
Telephone call
Please give a brief description of the reason you are seeking therapy/counseling at this time.
*
Your answer
Do you plan on using insurance or to pay out of pocket?
In network insurance benefits
Out of network insurance benefits
Out of pocket / self-pay
Other:
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If you plan to use your insurance, please indicate what insurance company or plan.
Your answer
Please note if you have any preferences for days/dates/times of your appointment. (I.e. "Tuesdays are usually best for me," "after the 17th of this month," "5pm or later," etc.)
Your answer
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