Wait List Form - Waiting

Waiting List

My practice is currently full. If you’d like to join the waiting list, please complete the form below. If a time becomes available that matches what you’ve indicated, I’ll contact you by text.

Joining the waiting list does not reserve or guarantee an appointment.

Full Name

First NameLast Name

Cell Phone:

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState

Zip Code

What type of therapy are you looking for?

How would you prefer to meet?

Briefly describe what brings you in:

What are the reason(s) you are here today?

Which weekdays and times could generally work for you?

Please include as much flexibility as you can — more options make it easier to match you with an opening. For example: Mondays 9–11, Wednesdays after 2, Fridays before noon.

When Can You Meet?

Rows	Mo	Tu	We	Th	Fr
7:30am - 8:10am
8:15am - 8:55am
9:00am - 9:40am
9:45am - 10:25am
10:30am - 11:50am
11:15am - 11:55am

If you’re seeking couples therapy, partner’s name:

First & Last Name

How did you find me?

Was there anything on my website that helped you decide to reach out?

Please verify that you are human