Appointment Request Form
To schedule an individual counseling session, couples counseling session, or family therapy appointment, or to register for one of our groups, fill out the form below or give us a call.
Your Phone Number
Your Email Address
Days and times during the week when you are available for counseling
Name of insurance or if you will be paying out of pocket
Out of Pocket
Does your insurance card says "Medicaid" or "Medicare" on it?
Counselor(s) you're interested in seeing
J. Robyn Mosley
Shawanna Burton (Self-Pay Only)
Becky Kim (Self-Pay Only)
Katy Janousek (Self-Pay Only)
Laura Howell (Cigna, UHC, Aetna, & Self-Pay Only)
Tim Pierce-Tomplin (Self-Pay Only)
A brief note about your primary counseling needs
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This form was created inside of Oasis Counseling Center.