Request a New Patient Appointment

Request a New Patient Appointment
Dr. Emick's testing and in-office therapy schedule is full. She is not accepting new testing or in-office therapy requests and has closed her waiting list for those services. However, at any given time, she may have an opening for telehealth appointments.
Name of person requesting the appointment*

First NameLast Name
Name of person for whom the appointment is being requested, if not yourself

First NameLast Name
Date of birth of the person for whom you are requesting the appointment*

MonthDayYear
Email address at which you can be contacted*
example@example.com
Telephone number at which you can be contacted*
Please enter a valid phone number.
Reason for appointment request*

Neuropsychological assessment (requires a referral from your healthcare provider)Psychotherapy
Please provide additional information*
Please note, some insurance companies contract with other insurance carriers to manage their behavioral health plans. Therefore, Dr. Emick may be a provider on your medical plan for the purposes of neuropsychological assessment, but not a provider on your behavioral plan for the purposes of psychotherapy. Providing your insurance plan and identification number will allow us to determine whether she is a provider on your appropriate insurance plan before an appointment is scheduled.
Your insurance plan and plan identification number. For example, United Healthcare 111111111 or Blue Cross Blue Shield XXX111111111. *
DateTime*
Please verify that you are human*
Should be Empty: