Request an Appointment

Therapy Appointment Request Form

Request an Appointment

Please complete the form below and a member of our team will reach out to help schedule your appointment. All information is kept confidential.

Section 1 Who Is Seeking Services?

Myself My Child/Dependent Couples Counseling Family Therapy

Section 2 Contact Information

First Name

Last Name

Date of Birth

Age

Phone Number

Email Address

Address (Optional)

Section 3 Client Information

Gender

Pronouns

Preferred Method of Contact

Phone Email Text Message

Section 4 Insurance & Payment

Insurance Provider

Member ID Number

Policy Holder Name

Self-Pay / Out-of-Pocket

Section 6 Session Preferences

Preferred Service Type

In-Person Telehealth Either

Preferred Days / Times

Day	Morning	Afternoon	Evening

Additional Availability Notes

Section 7 Communication Consent

This form is not monitored for emergencies

If you are experiencing a mental health crisis or medical emergency, call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline by dialing 988.

Thank You

Thank you. Our team will be in touch to schedule your appointment.