New Patient Appointment Request Form

New Patient Appointment Request Form

Please Complete
If you have never been seen at the Meridian Group before, please complete this form to request a first appointment. If you do not already have an appointment, you will be contacted by email or telephone within two to three business days to let you know what is available. All information is confidential. If you have any questions, call our office at 804-751-8644.
Client Name*

First NameMiddle InitialLast Name
Parent / Guardian Name (if client is a minor)

First NameLast Name
Clinician(s) Preference

John Dwyer, PhD Licensed Clinical PsychologistMelissa Findlay, LCSW Licensed Clinical Social WorkerJill Sexton-Newton, LPC Licensed Professional CounselorLeah Harlan, LPC Licensed Professional CounselorCrystal Cordes, PhD Licensed Clinical PsychologistJulianne Luck, MSW, Supervisee in Social WorkDavid Epstein, PsyD Licensed Clinical PsychologistElizabeth Novak, LCSW Licensed Clinical Social WorkerUnsure or no preference
What type of services are you seeking?

Counseling / PsychotherapyPsychological TestingCo-ParentingOther
Please describe the reason you are seeking services. *
You will have an opportunity to provide more detail after you have made an appointment with one of our clinicians on the Adult or Child/Adolescent Form
Client Age*
Client Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther (please describe)
Email (client or parent)*
Adult patient or parent/guardian
Primary Phone Number*
Adult patient or parent/guardian
Please confirm we may contact you by telephone or email*

Yes
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employment/School*

WorkingWorking and Attending SchoolAttending SchoolNoneOther: Please Describe
Who referred you to our office?*
Primary Care Provider*
Type "none" if you do not have a PCP
Insurance information
Primary Insurance Name*
If not insured or wish to not use insurance type "self pay"
Primary Insurance Subscriber or Member ID*
Type "None" if self-pay
EAP (Emploee Assitance Program)

Please complete the following questions if you would like to use EAP benefits (otherwise leave blank). Please note that not all EAP are accepted by providers and our psychologists do not accept EAP benefits. Please include insurance information (above) in case your EAP benifts are not accpetted or your EAP benfits are exhausted.
Name of EAP
Your Name *
Thank you for completing this form. You will be contacted to set up an appointment. If you have any questions, please call our office at 804-751-8644.
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New Patient Appointment Request Form

Insurance information