Request an Appointment

Is this request for an existing or a new Patient?**

Patient Legal Name:*

First NameLast Name

Patient Date of Birth*

Date

Relation to Patient*

Requester Name (if not Patient)*

Requester Age (if not Patient)**

Patient / Parent Phone Number*

Patient / Parent Email Address**

example@example.com

Service type you are seeking*

Please select primary service desired. If you require more than one service please call our offices after this form is submitted).*

Type of Psychological Testing*

Other Testing - Describe The Type of Psychological Testing*

Type of therapy*

Issue*

Issue - Other (Not Listed)*

Type in the issue in the box

Insurance Carrier*

Insurance Member ID number

Days available for weekly recurring appointments*

Do you have a certain clinician you are interested in working with?*

Select your preferred clinician:*

If the preferred clinician is not available, are you willing to see a different clinician?*

Do you have a preference for in-person or virtual appointments?*

If 'In-Person' what is your preferred location?*

State

The state the patient would be residing if services were rendered virtually.

Please note that we are currently only offering comprehensive evaluations for clients that are under 22 years old. Additionally, the evaluator for these evalutaions is an out of network provider. This means that evaluation will be at the private pay rate of $2950. Our office can provide a superbill for those that have out-of-network benefits.

Please give a brief description of what you are seeking help with**

Referred By*

Other Referred By*

Would you like to receive email newsletters from our practice?*

YesNo

Please verify that you are human*

Unfortunately, this clincian only provides psychological testing and does not provide psychotherapy.

We apologize, the provider you selected is not currently accepting new clients.

We apologize, we currently do not have any upcoming availability for the specific service you selected.

We apologize, we currently do not have any upcoming availability for the specific service at the office location you selected.

Task Mgt

Task Mgt Provider

Task Mgt Office Location

Task Prefix Provider

Task Prefix Office Location

Task Prefix CC

SR Prefix

2. SR Psych Testing

Psych Testing In Person Filler

Deal Breaker Answer

Current Date

Date

Age

Appointment Request Form