You can always press Enter⏎ to continue
WS Appointment Change Form
Welcome!
12
Questions
START
HIPAA
Compliance
1
Client Name
*
This field is required.
Name of CURRENT CLIENT. Please provide the client's first and last name below.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Client's Initials
*
This field is required.
Initials of the CURRENT CLIENT. Please enter the client's initials below.
Previous
Next
Submit
Press
Enter
3
Client Date of Birth
*
This field is required.
Please enter the client's DOB in the following format XX/XX/XXXX
Previous
Next
Submit
Press
Enter
4
Client Phone Number
*
This field is required.
This phone number should be where WS staff can communicate privately and securely regarding scheduling and other communications. Please provide a phone number that is private and WS staff may leave a message.
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
5
Client Email
*
This field is required.
This email should be where WS staff can communicate privately and securely regarding scheduling and other communications. Please provide the email of the client or client representative below.
example@example.com
Previous
Next
Submit
Press
Enter
6
HIPAA Verification of Identity Compliance Requirement
*
This field is required.
Please take a picture of the valid state issued identification of the client or the client's parent for HIPAA verification of identity compliance. WS cannot accept this request without HIPAA verification of identity.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
7
WS Clinician - Who is your WS therapist?
*
This field is required.
Please choose from the drop down menu below.
Danielle C. Ellis MA MCJ LPC NCC
Jason Stewart LPC
First Available
No Preference
Danielle C. Ellis MA MCJ LPC NCC
Jason Stewart LPC
First Available
No Preference
Previous
Next
Submit
Press
Enter
8
Appointment Management:
I am a current client and I would like to.....
*
This field is required.
Current Clients are clients in the WS community who have had an appointment within the past 60 days.
If you are a client of WS and you have not had an appointment in the past 60 days please complete the WS Appointment Request Form for new and readmitting clients. (This is a healthcare rule and not a WS rule. We apologize for the inconvenience.)
Schedule A Single Appointment
Reschedule A Single Appointment
Cancel A Single Appointment
Schedule My Standing/Recurring Appointment Series
Reschedule My Standing/Recurring Appointment Series
Cancel My Standing/Recurring Appointment Series
Schedule A Monthly Appointment or As Needed Appointment
Reschedule A Monthly or As Needed Appointment
Cancel A Monthly or As Needed Appointment
Previous
Next
Submit
Press
Enter
9
If Applicable: What is the Effective Date for the Schedule or Reschedule Request:
-
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
10
If Applicable: What is the Date of the Appointment Cancellation?
-
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
11
Appointment Availability to Schedule or Reschedule
*
This field is required.
Please click on ALL appointment spots convenient to your schedule. The more availability you are able to provide the more likely we are to provide an appointment within 7 days. Appointments that are 3 PM and later Monday-Friday and appointments on the weekends are the most requested times which may result in scheduling delays.
IF THIS DOES NOT APPLY TO YOUR REQUEST PLEASE CLICK ONE OF THE BOXES IN THE N/A ROW-OTHERWISE YOU WILL NOT BE ABLE TO PROCEED AND SUBMIT YOUR FORM.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7 AM
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
8 AM
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
9 AM
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
10 AM
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
11 AM
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Noon
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
1 PM
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
2 PM
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
3 PM
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
4 PM
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Row 9, Column 6
5 PM
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Row 10, Column 5
Row 10, Column 6
6 PM
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Row 11, Column 5
Row 11, Column 6
7 PM
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Row 12, Column 5
Row 12, Column 6
8 PM
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Row 13, Column 5
Row 13, Column 6
N/A
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Row 14, Column 5
Row 14, Column 6
7 AM
8 AM
9 AM
10 AM
11 AM
Noon
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
N/A
Monday
Row 0, Column 0
Tuesday
Row 0, Column 1
Wednesday
Row 0, Column 2
Thursday
Row 0, Column 3
Friday
Row 0, Column 4
Saturday
Row 0, Column 5
Sunday
Row 0, Column 6
Monday
Row 1, Column 0
Tuesday
Row 1, Column 1
Wednesday
Row 1, Column 2
Thursday
Row 1, Column 3
Friday
Row 1, Column 4
Saturday
Row 1, Column 5
Sunday
Row 1, Column 6
Monday
Row 2, Column 0
Tuesday
Row 2, Column 1
Wednesday
Row 2, Column 2
Thursday
Row 2, Column 3
Friday
Row 2, Column 4
Saturday
Row 2, Column 5
Sunday
Row 2, Column 6
Monday
Row 3, Column 0
Tuesday
Row 3, Column 1
Wednesday
Row 3, Column 2
Thursday
Row 3, Column 3
Friday
Row 3, Column 4
Saturday
Row 3, Column 5
Sunday
Row 3, Column 6
Monday
Row 4, Column 0
Tuesday
Row 4, Column 1
Wednesday
Row 4, Column 2
Thursday
Row 4, Column 3
Friday
Row 4, Column 4
Saturday
Row 4, Column 5
Sunday
Row 4, Column 6
Monday
Row 5, Column 0
Tuesday
Row 5, Column 1
Wednesday
Row 5, Column 2
Thursday
Row 5, Column 3
Friday
Row 5, Column 4
Saturday
Row 5, Column 5
Sunday
Row 5, Column 6
Monday
Row 6, Column 0
Tuesday
Row 6, Column 1
Wednesday
Row 6, Column 2
Thursday
Row 6, Column 3
Friday
Row 6, Column 4
Saturday
Row 6, Column 5
Sunday
Row 6, Column 6
Monday
Row 7, Column 0
Tuesday
Row 7, Column 1
Wednesday
Row 7, Column 2
Thursday
Row 7, Column 3
Friday
Row 7, Column 4
Saturday
Row 7, Column 5
Sunday
Row 7, Column 6
Monday
Row 8, Column 0
Tuesday
Row 8, Column 1
Wednesday
Row 8, Column 2
Thursday
Row 8, Column 3
Friday
Row 8, Column 4
Saturday
Row 8, Column 5
Sunday
Row 8, Column 6
Monday
Row 9, Column 0
Tuesday
Row 9, Column 1
Wednesday
Row 9, Column 2
Thursday
Row 9, Column 3
Friday
Row 9, Column 4
Saturday
Row 9, Column 5
Sunday
Row 9, Column 6
Monday
Row 10, Column 0
Tuesday
Row 10, Column 1
Wednesday
Row 10, Column 2
Thursday
Row 10, Column 3
Friday
Row 10, Column 4
Saturday
Row 10, Column 5
Sunday
Row 10, Column 6
Monday
Row 11, Column 0
Tuesday
Row 11, Column 1
Wednesday
Row 11, Column 2
Thursday
Row 11, Column 3
Friday
Row 11, Column 4
Saturday
Row 11, Column 5
Sunday
Row 11, Column 6
Monday
Row 12, Column 0
Tuesday
Row 12, Column 1
Wednesday
Row 12, Column 2
Thursday
Row 12, Column 3
Friday
Row 12, Column 4
Saturday
Row 12, Column 5
Sunday
Row 12, Column 6
Monday
Row 13, Column 0
Tuesday
Row 13, Column 1
Wednesday
Row 13, Column 2
Thursday
Row 13, Column 3
Friday
Row 13, Column 4
Saturday
Row 13, Column 5
Sunday
Row 13, Column 6
Monday
Row 14, Column 0
Tuesday
Row 14, Column 1
Wednesday
Row 14, Column 2
Thursday
Row 14, Column 3
Friday
Row 14, Column 4
Saturday
Row 14, Column 5
Sunday
Row 14, Column 6
1
of 15
Previous
Next
Submit
Press
Enter
12
Signature
*
This field is required.
With my signature below I give WS permission to use the contact information provided in order to begin the appointment scheduling process. I understand that the submission of an appointment request is not a guarantee of an appointment. Please sign the below request.
Clear
Previous
Next
Submit
Press
Enter
13
Timer
Previous
Next
Submit
Press
Enter
14
Previous
Next
Submit
Press
Enter
15
Unique ID
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
15
See All
Go Back
Submit