Scheduling Request-Nia Noire
Please complete this form.Our intake specialist will reach out to you to help set up your initial appointment via email.
Our waitlist is currently closed.
Please check back at a later date for openings.
I acknowledge that this submission is for the Waitlist only at this time
Yes, I understand
Date of Birth
Gender - as identified by Insurance
Self- Identified Gender
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Please enter a valid phone number.
Insurance Subscriber ID
Services Interested in:
Individual Therapy(Ages 16 & up)
How did you hear about our practice?
Please provide your normal availability
I prefer Morning
I prefer Afternoon
I prefer Evening
Notes - Please enter any additional information that you would like to provide.
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One-time Admin Fee
This Virtual Mental Health Practice uses a HIPAA Compliant third party administrative firm to retrieve your inquiry for services. The submission of this form is non refundable and not a guarantee of services. Should we respond to any form submission and we do not receive a response in a timely manner (2 business days) - We reserve the right to suspend a client's service request or cancel the client's submission. This is a one-time, non refundable fee. We reserve the right to change the prices of our service at any time. The payment of this fee guarantees that the Mental Health practice that you are attempting to reach will receive your inquiry, provide a cost estimate for requested services, and scheduling options in a HIPAA Compliant and timely manner.
Credit Card Details
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