Request an Appointment with Jeffrey

Congratulations on taking the first steps toward wellness and becoming the best version of yourself. Before we schedule our first session, please take a few moments to complete this form. Your responses will help me understand your needs, determine whether we are an appropriate fit, and ensure that I can serve you effectively and ethically.

I appreciate your willingness to share this information, and I look forward to learning how I can best support you on your journey!

Blessings,

Jeffrey S. Lewis Jr., MA, ALC

Name

First NameLast Name

Age

Phone Number

Email

example@example.com

Reasons for Seeking Therapy

Do you have a preference for Day of Week and Time of Day, or would you like a first available appointment?

How frequently do you prefer to meet?

I prefer to meet:

In Person: TuscaloosaTelehealth

Our rates are $150/Assessment and $130/55 minute session. Please select your preferred method of payment.

I plan to private payI plan to utilize insurance (Jeffrey accepts Blue Cross Blue Shield, BHS, and Cigna)

If you plan to use insurance, what kind of insurance do you have?

Do you have any questions before we schedule?

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