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Request an Appointment
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* Indicates required question
NAME of person requiring services
*
Your answer
AGE if person is a minor
Your answer
TELEPHONE
(xxx) xxx-xxxx
Your answer
EMAIL
Your answer
How would you prefer to be contacted?
By email
By telephone
Clear selection
If by telephone, please indicate if it is acceptable to leave a message?
Yes
No
Clear selection
WHEN are you available for APPOINTMENTS?
Please note that we cannot always accommodate preferred appt. times.
Your answer
How will you be PAYING for services?
Self Pay
Health Insurance
Clear selection
Name of Health Insurance:
Your answer
REASONS you are seeking services (you may choose more than one):
*
Medication
Therapy
Testing
Required
If you selected therapy, please share briefly why you are seeking services, e.g., couples counseling, depression, anxiety, etc.:
*
Your answer
Request a particular PROVIDER (you may choose more than one):
No preference
Caroline Augustin, LPC
Jessica Bardenheier, MS, LPC
Teresa A. Buczek, Ph.D.
Wendy Cohen, MD
Katharine B. Fitzhugh, Ph.D.
Brandy Hart, L.C.S.W.
Mary Brantley Holmes, WHNP (Women’s Health Nurse Practitioner)
Jeff Knighton, LCSW
Nancy MacConnachie, Ph.D.
Hank Matthews, LPC, CSAC
Jennifer Mixan-Darden, LPC
Eric J. Oritt, Ph.D.
Jesse Pearlstein, LCSW
Margaret Rittenhouse, LCSW
Anne M. Sitarz, Ph.D.
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