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Please fill out the form below to request an appointment.

Client's Name Required

Client's Phone Required

Email Required

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Additional info or requests

If selected "other" please list here

Location Required

Preferred Appointment Format

Either Telehealth or In Person

Telehealth

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Insurance Required

*Please notice that communicating via email and over the Internet is not secure. Even though it is unlikely, it is possible that your email might be intercepted and read by people other than your intended recipient. Required

I have read and understand the disclaimer.

To expedite scheduling, please also provide the following information. Thank you!

Full Legal Name of Client

Date of Birth

Full Address (including city, state and zip code)

Insurance ID/Member Number

Insurance Group Number (if applicable)

Email address for patient portal (Please note, this email must be for the client if 18+ or a legal guardian for minors.)

We offer appointment reminders. Would you like this via:

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Any scheduling preferences? (Please note, we have very high demand so the more flexible you are, the more likely we are to have options for you.

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