Appointment Request Form

Appointment Request

Dionne Aldridge, LCSW-C 443-416-5833 Dionne.Aldridge@gmail.com
Today's Date

MonthDayYear
Date
I am off on 3/15/26, 3/22/26, 3/30/26, 4/16/26, 4/17/26, 4/20/26. Please do not schedule on these days. It will still show up on my calendar as an option, but do not select that day.
Initials
New Schedule January 2026

Office Hours

Monday-6-8pm

Tuesday-closed

Wednesday-closed

Thursday-12-9pm

Friday-12-2pm (phone sessions only)

Saturday-Closed

Sunday-11-1pm
Person #1

First NameLast Name
Person #2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What Service? Individual counseling, couples counseling, Family Therapy, Initial phone consultation, Private Tutoring (SW Exam Prep session or consult).
NEW Therapy Video Link for All Sessions on the website: Inspiringcounseling.net Private Tutoring (zoom link will be emailed)
initials
Form of Payment? Self Pay, Insurance (Name), EAP (Name) *
Initials Required. Your appt is not scheduled until you receive a confirmation email or text. This form is only to request an appt. Appt requested may not be available. I will text you alternative options. *
initials
Initials Required. All Payments/Co-pays are due prior to your session. Alma clients must put a card on file for copayments. Thank you.*
initials
Write Note to Dionne Aldridge
*No longer completing FMLA forms
Initials Required. All appt must be confirmed 24 hours in advance via email or text 443-416-5833. Appt will be cancelled w/o confirmation. $60 No Show fee. *
initials
Appointment*
I am off on 3/15/26, 3/22/26, 3/30/26, 4/16/26, 4/17/26, 4/20/26. Please do not schedule on these days. It will still show up on my calendar as an option, but do not select that day.
Initials
Should be Empty: