New Patient Inquiry Form

New Patient Inquiry

Please fill in the form below
Name

First NameMiddle NameLast Name
Contact Number:

Area CodePhone Number
E-mail
Date of Birth

MonthDayYear
Sex
Marital Status
Please, indicate what type of therapy you are interested in
Please, briefly state what you would like to address in therapy
Payment Information:

In an effort to make psychological services more available, Dr. Burkhart offers a sliding fee scale based on your gross monthly income.
Please, select your gross monthly income
We will use this information to determine your session rate.
How did you hear about Dr. Burkhart's Practice?
If other, please specify
Dr. Burkhart's office will be in touch with you to discuss therapy options and availability.

Thank you
Should be Empty: