Appointment Request Form

1

Full Name* This field is required.

First Name

Last Name

2

Your Cell Phone* This field is required.

Area Code

Phone Number

3

Your Email Address* This field is required.

example@example.com

4

Are you seeking services for ..........?* This field is required.

yourself

You and your partner

5

Partner's Full Name (if seeking couple's services),.....otherwise skip this question.

First Name

Last Name

6

Partner's Email (if seeking couple's services),,,,,other wise skip this question.

example@example.com

7

How are you planning to pay for these services?Please check only 1 answer: Please note I am NOT able to bill Aetna, MaineCare, Medicare, Medicaid, TriCare, AARP

Totally out of pocket without insurance

Anthem BCBS

Cigna

Harvard Pilgrim

Health plans Inc

Community Health Options

UMR

United Health Care

9

When possible appointment time slots are reserved on a consistent basis. Is it possible to have your future appointment times consistently scheduled at the times you selected above?

YESNO

10

Briefly, what are your reasons for seeking these services* This field is required.

11

I look forward to meeting you soon.

Respectfully,

Bill Gould LCPC