Request an Appointment

Scheduling An Appointment

Once this form is completed and submitted you will receive an email with my availability. You will also receive additional emails requesting the information below. Please be aware that your appointment is will not be confirmed until all information had been received.

Signed Informed Consent (emailed)
Insurance Card (if applicable)
Credit Card on file (IVY Pay)

Client Information

Please double check all information entered to ensure that all information is correct.

First Name

Middle Name

Last Name

Preferred First Name

Street Address

City

State

Zip Code

Date Of Birth

Last 4 of SS#

Home Phone Number

Mobile Phone Number

Please make sure to enter your correct phone number

Email address

I am interested in... Select All That Apply

Individual Counseling

Couples Counseling

Consulting

Session Preference Select All That Apply

Virtual (Video and Audio)

Phone (Audio only)

I Plan to...

File Through Insurance

Pay Out Of Pocket

Emergency Contact

I have double checked all information to ensure that all my information is correct.

Your information will be encrypted.