Appointment Request Form

Sliding Scale Rate Eligibility

Our current therapist who offers a sliding scale reduced rate is James Lehnardt, PLPC. To determine the therapy rate you would qualify forwe need the following information.

Number of people in your household blanks
Estimated Annual Income: fill in the blank
*Verification of income may be requested

We will email you back with the therapy rate you qualify for along with directions on how to get set up as a client if you are interested in proceeding.
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.
Client Name *

First Name Middle Initial Last Name
Preferred First Name (if different)
Primary Phone Number *

Area Code Phone Number
Primary Email *
example@example.com
Client's Date of Birth *
Gender

Male Female Other
List all individuals who would be attending the family therapy sessions *
Spouse/Significant Other’s Name *

First Name Last Name
Spouse/Significant Other Preferred First Name (if different)
Spouse/Significant Other's Phone Number *

Area Code Phone Number
Spouse’s/Significant Other’s Email *
example@example.com
Spouse/Significant Other's Date of Birth *
Spouse/Significant Other's Gender

Male Female Other
Person filling out this form's Name *

First Name Last Name
Relationship to Client
Person filling out this form's Phone Number (if different from client)

Area Code Phone Number
Person filling out this form's Email (if different from client)
example@example.com
Should be Empty:

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Contact Information