Appointment Request Form

  • Request an Appointment

    Fill out the below questionnaire to see if we have a therapist available who can meet your needs. Most sessions are being held in-person.

  • Scheduling Note: Most of our therapist only have DAYTIME availilbility at this time.  If you are needing consistent late afternoon/evening or weekend appointments, try back again later to see if our status has changed. 

  • Client Status*
  • Who was your therapist?*

  • Approximately how long ago was your last appointment*
  • Who are you seeking an appointment for?*
  • Mark the type of therapy you are looking for.*
  • Mark the appropriate age range of the client to see if we have a therapist available to work with you. *For family sessions you must mark the YOUNGEST member who will be a part of the family counseling session.*

  • I'm sorry. We do not have a therapist who is accepting new clients at this time who meets this criteria.  Please try back again later to see if our status has changed.

  • Help Us Find the Right Therapist for You

  • Are you wanting to make an appointment with the same therapist you have seen previously.*
  • Therapist Criteria*
  • Which therapist were you hoping to see? *Note--Not all therapist are accepting new clients at this time, if the therapist you select is not available, we will let you know if we have other therapists available to work with you.*

  • Preference on Therapist's Gender*
  • Payment Method Preference*
  • Do you have insurance that you would like us to get a quote of benefits from to compare insurance costs to self-pay options?
  • Select the type of Insurance plan you have*

  • Unfortunately, we CANNOT accept your insurance at our office. 

    If you would like to continue as a self-pay client, please look at the self-pay options below. If you are not interested in a self-pay option, you will need to find another provider's office who can accept your insurance.  

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  • Therapist Licensure Preference (To increase your chances of finding a therapist with an opening, mark all that would be acceptable; we will give you a chance to put in order of preference on the next question)
  • Would you like to provide information so we can determine the rate you would qualify for if there is a provisionally licensed therapist available?

  • Sliding Scale Rate Eligibility

    Sliding scale is only offered for therapy performed by a provisionally licensed therapist. If a provisionally licensed therapist is not available, a sliding scale will NOT be an option.
  • Self-Pay Options--All choices will be based on therapist availability (Mark all that would be acceptable to you to increase your chances of finding a therapist with an opening, we will give you a chance to put in order of preference on the next question)*
  • If you would like to use insurance, our first choice would be to put you with a therapist who can take your insurance. In the event that we do not have a therapist who is accepting new clients who can meet your needs, please mark any other alternative self-pay options you would be willing to explore (Mark all that would be acceptable to you to increase your chances of finding a therapist with an opening)*

  • Contact Information

    If we have a therapist available that meets your needs, we will email you some paperwork so we can finish setting up an appointment.

  • *Please Note: Each person will need to complete a set of their own paperwork.  We will create a couples chart for those sessions done together and separate individual charts should either client want to break out for individual sessions.

  • For billing purposes, each family chart must have ONE person's name as the primary client.  When filling out the client information, please enter the name of the person who you would like us to set up the chart and bill under.

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  • Gender
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  • Spouse/Significant Other's Gender
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  • Should be Empty: