Appointment Request Form
Please complete the form below, and we will get in touch as soon as possible to answer any questions, discuss how we can best help, and schedule your appointment.
Name
*
First Name
Last Name
Age
*
Email
*
example@example.com
How did you hear about us?
*
Please Select
Another behavioral health professional
A current or former client
Google/Search Engine
Friend or Family Member
Psychology Today
Social Media
YouTube
Court/Probation Department
JLAP
Other
Court/Probation Contact Person and Agency
Example: Jane Doe, Marion Superior Court Probation
Professional and Agency
Example: Jane Doe, Daydream Therapy
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
May we contact you via text message at this number?
*
Yes
No
May we leave a voicemail message at this number?
*
Yes
No
Which services are you interested in? (check all that apply)
*
Individual Therapy
Couples/Family Therapy
Gambling Treatment
Substance Use Treatment
AIP/BIP: Abuse Intervention Program for Men
Peer Recovery Support Services
Other
Preferred Therapist
*
Please Select
Dr. Eric L. Davis, DSW, LCSW, LCAC
Erin Davis, MSW, LCSW
Jeff Gasior, CAPRC (Peer Recovery Specialist)
No Preference
Anything else you feel is important for us to know to best help you
Are there any referral documents or other relevant paperwork you would like to attach to your appointment request?
Please Select
No
Yes
Please upload any referral documents or paperwork (if applicable)
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