Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Reason for Appointment
Name and age(s) of client(s)
Location(s) (check all that apply)
Marietta
Alpharetta
Duluth
Dunwoody (Dr. Ram/Medication management only)
New Orleans
Portland (Virtual Only)
Virtual
Preferred therapist or psychiatrist (check all that apply): *Note the more open you are the more likely you are to get a quicker appointment
No preference/any
Dr. Ram (Duluth/Dunwoody/telehealth)
Meredith Mitchell, PMHNP (Marietta/telehealth)
Alan Behrman (Marietta/telehealth)
Silvia Lynch (Marietta)
Tu Vo (Marietta/telehealth)
Patty Postanowicz (Marietta/telehealth)
Jamie Goldberg (Marietta/telehealth)
Emma Green (Marietta/Duluth/Alpharetta/telehealth)
Ariella Peist (Alpharetta/telehealth)
Christina Lazaro (Alpharetta/Duluth/telehealth)
Kelly Villarreal (Alpharetta/telehealth)
Mona Chandra (Alpharetta/telehealth)
Whitney Rudd (Marietta/telehealth)
Jessica Bosson (Duluth/telehealth)
Kailyn Blackmon (Duluth/telehealth)
Sheldon Kay (Duluth/telehealth)
Rachel Barlev (telehealth)
Ashlie Martinez (New Orleans/Portland/telehealth)
David Dolese (New Orleans/telehealth)
Ashely LeGros (New Orleans/telehealth)
Rae Sidlauskas (New Orleans/Portland/telehealth)
Ashley Lee, NP (New Orleans/telehealth)
Insurance (check all that apply): *Note that not all therapist take insurance and not all therapists take the same insurances
Aetna
BCBS
Humana
Carelon
Oxford
Oscar
Tricare
UnitedHealthcare
Medicare
Out of network (will accept private pay)
Preferred day of appointment (check all that apply)
First available or doesn’t matter
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday morning
Preferred time of appointment (check all that apply)
First available or doesn’t matter
Morning (7 am - 10 am)
Midday (11 am - 2 pm)
Afternoon (3 pm - 5 pm)
Evening (6 pm - 8 pm)
Submit
Should be Empty: