Appointment Request Form

Please correct the errors described below.

Please use this secure form to request an initial appointment for therapy. Our Client Coordinator Christine will contact you within 2 business days. We look forward to working with you!

Contact Information

Date & Time

While we cannot guarantee that we can accommodate your scheduling needs, we will take this into consideration.

Client Information

In order to assign an appropriate therapist, we need to know the client's age. Also, having date of birth helps us to check insurance benefits.
Having your member number enables us to check your mental health benefits, so we can provide better information when we contact you.

This is only a request for an initial appointment and does not guarantee an appointment, nor does this establish a therapist-client relationship. We will review the information you have provided to determine if we have a therapist available who would be a good fit for you. Please allow up to 2 business days for a response.

Your information will be encrypted.