Appointment Request

Mental Health Emergency Info

If this is an emergency, call:

24/7 Child Crisis Line: (502) 589-8070
24/7 Adult Crisis Line: (502) 589-4313
911

Client Information (Enter information for the person in need of services)

I'm a current or previous client

I'm a new client

First name

Last name

Email Address

Phone Number

Date of Birth

Current School and Grade Level

*For clients currently enrolled in school

Parent/Guardian First Name (if applicable)

Parent/Guardian Last Name (if applicable)

Address (Street Name, City, State, Zip Code)

Parent/Guardian Phone Number (if applicable)

Parent Email Address (if applicable)

Preferred Days/Times For Scheduling Initial Appointment

Preferred Day(s)

Initial intake appointments are scheduled Mondays-Fridays.

Time(s)

Initial appointments are typically 60-75 minutes, and can be schedule between 11:00 AM to 7:30 PM.

Reason For Your Appointment Request

What is your reason for seeking treatment? What are you (or your child) struggling with right now?

What do you hope to achieve by seeking services with us?

Service(s) Requested:

Psychological Assessment (Adults)

Psychological Assessment (age 5-17)

Individual Therapy

Dyslexia Therapy/Remediation

Executive Function Coaching

Other Educational Therapy Services

Insurance Options

Humana

Aetna

Self Pay/Out-of-Network Benefits

Please enter the following information from your Humana or Aetna insurance card.

Member ID Number

Group Number

Primary Policyholder Name

Primary Policyholder DOB

Additional information

If there's anything else that you would like us to know or tell us about, please include it here.

Your information will be encrypted.

Appointment Request

Mental Health Emergency Info

Client Information (Enter information for the person in need of services)

Preferred Days/Times For Scheduling Initial Appointment

Reason For Your Appointment Request

Mental Health Emergency Info

Dreamcloud Psychology & Educational Services, LLC