Appointment Request

Appointment Request
Date:

MonthDayYear
Date+:

YearMonthDay
Full Name:
Appointment Type:

IntensiveGAMHA
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Age:
Parent/Caregiver:

First NameLast Name
Parent/Caregiver Full Name:
Scheduling Contact:

First NameLast Name
Scheduling Contact Full Name:
Email:*
Phone Number:
Preferred Contact Method:*
Appointment Type:*
Session Type:*

Any / First AvailableTelehealth OnlyIn-Person Only
Office Location(s):*

Uptown DallasPlanoRockwallDentonMcKinneyAny (No Preference)
Preferred Therapist:*
Have you visited us before?*

Yes (Returning Client)No (New Client)
Please tell us a bit about your availability for appointments. What days and times work best?*
Will you be using insurance?*

YesNo
Name (as it appears on the insurance policy):
Insurance Company:

AetnaBlue Cross Blue ShieldCignaScott & White Health PlanTRICAREUnited HealthcareOut-of-Network BenefitsOther

Policyholder's Name:
Insurance ID Number:
If you are comfortable doing so, please share a little more about why you are seeking therapy so that we may better understand your needs:
Would you please let us know a little more about what brings you to therapy and, more specifically, why you are seeking EMDR Intensive Therapy?
Should be Empty: