Online 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

New Client Information

*Denise Myers, M.Ed. LPP is not accepting any new therapy clients under age 13 at this time.

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 typically scheduled Mondays-Fridays before 4:30 pm.

Time(s) Available

Initial appointments are typically 60-75 minutes. There is limited availability for late evening appointments.

Reason For Your Appointment Request

What is your reason for seeking services? 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 - age 18-45)

Psychological Assessment (age 5-17)

Individual Therapy (age 12 and older)

Dyslexia Therapy/Remediation (age 5 through adulthood)

Executive Function Coaching (age 12-18)

Other Educational Therapy Services (age 5 and older)

Insurance Options

Aetna (Commercial Plans)

Self Pay/Out-of-Network Benefits

Please enter the following information from your 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.

Online Appointment Request

Mental Health Emergency Info

New Client Information

Preferred Days/Times For Scheduling Initial Appointment

Reason For Your Appointment Request

Mental Health Emergency Info

Dreamcloud Psychology & Educational Services, LLC