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Appointment Request
Please fill out this form completely so that we may accurately and efficiently get you scheduled with one of our therapists. Appointment requests will be confirmed by the practice.
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* Indicates required question
Email
*
Your email
Name (First and Last)
*
Your answer
Phone Number
*
Your answer
Method of Payment (Insurance of Self-Pay)
*
Aetna Better Health
Amerigroup
BCBS
Cigna
Community First Health Plan
Compsych
Humana
Optum/GEHA
Superior
Traditional Medicaid
Tricare (out of network)
United Health Care/Optum/Oscar
Self-Pay (full rate)
Sliding Scale (will be booked with an student/intern if available)
Required
Type of Counseling Requested
*
Individual - Adult
Individual - Teen
If you selected other, please explain below.
Your answer
Select Clinician
*
Ginny Dalton, LCSW (Teens-Adults)
Bethany Hofman (Sliding Scale-Teens to Adults)
No preference
Required
Select Location
*
Telehealth
Office (11901 Toepperwein Suite 1202, Live Oak, TX 78233)
Required
Day/Time Preference
Mornings 8-Noon
Afternoon 12-4
Evening 4-7
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Mornings 8-Noon
Afternoon 12-4
Evening 4-7
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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