New Client Inquiry

Please fill out this brief form to give more information for your next steps.

Name

Phone Number

Email Address

How would you like to have your sessions? Note: No in-person sessions are available for VT and FL (Telehealth Only)

Telehealth (Video/Phone)

Phone only may restricted by insurance and other guidelines

In-person/Office

By appointment only. Based on availability

Both (I want flexibility)

If you would like to just proceed with setting up an appointment jump to the "SECTION 2" of the form.

What is your schedule like, are there best available times for you during the week?

Please take note of your selected provider availability.

Would you like to schedule a free 10-15 minute consultation before booking an appointment?

SECTION 2: FILL OUT THIS SECTION TO PROCEED WITH BOOKING AN APPOINTMENT.

Please answer the following questions and upload the requested documents:

What is your availability? Availability is based on selected Provider Schedule.

Please feel free to give multiple time frames. We will try to give you an appt that is within your preferred timeframe but cannot guarantee this. If you are an EAP referral and received an appointment time please enter here.

Add a brief description of why you are seeking support (Optional)

Will you be using insurance? Insurance coverage may be based on network, plan and location.

Yes

I have insurance but will be using EAP Benefits

Be sure to enter your EAP details at the end of the form.

I would like to discuss my options further

If Yes, what is the name of your Health Insurance provider?

Files

Add file

Please upload a file

Please upload a copy of your Photo ID below:

Files

Add file

Please upload a file

Please upload a photo of your insurance card (Back and front)

Files

Add file

Please upload a file

I will be using EAP Benefits

Enter your EAP Provider here (Ex. Aetna, Health Advocates, Cigna)

Enter Number of approved sessions and Authorization # (if applicable)

Your information will be encrypted.

Jodyan Gaynor, LPC

Appointment Availability (MON-FRI)

Whitney Wilfred, LCSW (Climbing Out Solutions) Appointment Availability : MON, WED, FRI, SAT)