Appointment Form

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Image Field
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Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
Confirm Email
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Are you 18 years of age or older?* This field is required.
YESNO
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Because of the state guidelines, our Therapy Services are only available to Georgia residents. However, we're also offering Coaching Packages that are not limited by state guidelines. What type of service are you looking to book with us?* This field is required.
Coaching Packages - Services include: Personal Coaching, Relationship Coaching, Stress Management, Career Building, Group Coaching, etc. Insurance does not apply.
Therapy Services - Services include: Individual Therapy, Couple Therapy, Family Therapy, Group Therapy, etc. Insurance coverage may apply.
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Please select from our Coaching Packages:Learn more about our coaching packages here https://shirleytherapeuticandconsultingservices.com/coaching-services/
Personal Coaching
Career Building
Relationship Coaching
Stress Management
Career Advice
Goal Setting
Closed Group Coaching
Open Group Coaching
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To set up your coaching package, we need a photo of the front of your driver's license. How do you want to send it?(Note: Providing the following information now will make the appointment process faster.)
I will upload it now
I will send it via email.
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File Upload - Driver's License (coaching services)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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To complete your booking, we'll need a photo of the front of your driver's license. How would you like to send it?(Note: Providing the following information now will make the appointment process faster.)
I will upload it now
I will send it via email.
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File Upload - Driver's License (therapy services)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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Please email the front of your driver's license to clients@shirleytherapeuticandconsultingservices.com.

You can also text it to us at 478-257-5534.
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What is your form of reimbursement?
Health Insurance
Self-Pay
Other
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We accept most major insurance plans plus CareSource, WellCare, PeachState, and Amerigroup. We need a copy of the front and back of your insurance card and the front of your driver's license. Sharing these now makes verification faster.How do you want to share these?
Upload now
Send via email
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File upload - Front of insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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File upload - Back of insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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Do you have another Insurance Card aside from the one you just sent?
YESNO
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Do you want to upload it now?(Note: Providing the following information now will make the appointment process faster.)
YESNO
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Upload a copy of the front of your other Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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Upload a copy of the back of your other Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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Please email the front and back of your health insurance card and the front of your driver's license to clients@shirleytherapeuticandconsultingservices.com.
You can also text it to us at 478-257-5534.
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Which one is your Primary Insurance?
Please Select
Please Select
The First Card that I sent
The Second Card that I sent
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Please email the front and back of your health insurance card and the front of your driver's license to clients@shirleytherapeuticandconsultingservices.com.
You can also text it to us at 478-257-5534.
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To set up self-pay option, we need a photo of the front of your driver's license. How do you want to send it?
I will upload it now (Note: Providing the following information now will make the appointment process faster.)
I will send it via email.
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File Upload - Driver's License
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
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Please email the front of your driver's license to clients@shirleytherapeuticandconsultingservices.com.

You can also text it to us at 478-257-5534.
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Who is your preferred Clinician after the intake?To learn more about our clinicians visit https://shirleytherapeuticandconsultingservices.com/meet-us/
Carla Whitehead, APC
Whoever is available
LaShonza “Shon” Dozier
Other
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What do you want us to know before your appointment?* This field is required.
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I agree to receive SMS updates from Shirley Therapeutic and Consulting Services, LLC, as described above. I understand that message frequency varies (1-4 messages per week, with additional messages possible during active conversations), and that standard message & data rates may apply. I can opt out at any time by replying STOP, UNSUBSCRIBE, or CANCEL to (478) 974-7002. For assistance, I can reply HELP or email clients@shirleytherapeuticandconsultingservices.com.* This field is required.
I agree
I do not agree
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I hereby certify that, to the best of my knowledge, the provided information is true and accurate.* This field is required.
Yes
No
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Signature* This field is required.
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