Consultation Appointment Request Form

How did you hear about Dr. NaMetris Blount

Full Name

First NameLast Name

E-mail

example@example.com

Phone Number

Area CodePhone Number

What is your current state and postal code?

Prefered method of contact for consultation?

What is your overall goal for this appointment and how would you know if that goal was met?

Please answer both parts of the question

How long have you been in business?

Describe your business and your current business model?

Traditional Practice, TeleHealth, Blended or other (Put N/A if this does not apply)

Share your social media platforms for professional use and your business website URL.

Consultation Needs Assessment for 2 hour sessions ONLY

Other

Describe your current business referral source

(Insurance, social media, teleplatforms, etc)

Other details you may wish to highlight

Scheduling Options in Eastern Standard Time Zone

***For all mental health counseling service requests please click the link below to be redirected to the correct website. This is not the correct form to complete for that service. Thank you.

Mental Health Counseling Services

CLICK HERE

Consulting Strategy Session Options

Consultation Appointment deposit Fee$15.00

This is the scheduling fee that is required in order to secure your consultation request. All appointments are in addition to this deposit.

45 Minute General Consultation (In addition to the 15 min Appointment)$110.00

This appointment type is a consultation session for 45 mins. This is ideal for those needing a single presenting concern processed. This consult is a processing session supported by Q & A only and does not includes handouts or drafted materials. Please see other services if you are in need of supporting materials and handouts.

2 hour consultation/strategy session Phone/Video$535.00

This appointment type is a complete consultation/strategy session for 120 mins. Select this if you are interested in a 2-hour consultation intensive session to clarify your presenting issues (i.e business model/ operational systems, securing multi-state licensure, and/or next steps in your business) that are in need of support. This session will include a deep dive with Q & As in addition to any applicable handouts/drafted materials to support your consultation needs.

Total $0.00

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Consultation Appointment Request Form

Consultation Needs Assessment

Thank you for your interest in scheduling a consultation appointment. Please note that the time you select for your appointment is in Eastern Standard Time.

Consulting Strategy Session Options