Consultation Appointment Request Form

Consultation Appointment Request Form

Make an Appointment with Dr. NaMetris Blount:
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?*

Phone Call (this is the number I will call for our appointment)Video/Virtual Session (Link will be provided by email prior to session)
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

Please select N/A if you are scheduling a 45 min Consultation.
Consultation Needs Assessment for 2 hour sessions ONLY*

General Career planning/DevelopmentResources and solutions for caregivers of individuals with Mental IllnessProfessionals and Current Students in the field of Mental Health and Wellness that are interested in TeleMental Health service deliveryHow to start a TeleMental Health Private PracticeSeeking guidance and resources related to TeleMental Health by StateSmall Business consulting to help increase knowledge on how to develop systems that reduce overhead costsOpen consult session based on needsN/A- I am seeking the 45 min Appointment session and theOther
Describe your current business referral source
(Insurance, social media, teleplatforms, etc)
Other details you may wish to highlight
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.

The contact information provided will be used for session contact.
Scheduling Options in Eastern Standard Time Zone*

AM 8:00 am - 11:00 am ESTPM 12:00 pm - 5:00 pm ESTMondayTuesdayWednesdayThursdayFridayBefore 8:00 am ESTOther
***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.