Schedule Appointment Name:(Required)Email:(Required) Phone:(Required)I’m available to make an appointment on (check all that apply): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preferred appointment time: Morning Afternoon Evening Any In-person or virtual appointment? In-person Virtual Mixed - Virtual and In-person No preference Would you be open to considering virtual therapy sessions if an in-person appointment isn't available at your preferred time? Yes No Location preference: Lakeview Andersonville No Preference Would you be open to considering the alternate location if an appointment isn't available at your preferred location?: Yes No Preferred payment method: Blue Cross Blue Shield PPO Aetna PPO Cigna PPO United Healthcare PPO Out-of-Pocket Age: Child/Adolescent <18 Young Adult 18-24 Adult 25+ Type of Service: Individual Therapy Couples Therapy Family Therapy Neuropsychological/Psychological Testing If known, reason for seeking therapy:Any additional comments or concerns: Δ
