Appointment Request Form 
Thank you for your interest in working with me.  Please note that I am only taking new patients who reside in California and who are currently in regular, ongoing therapy.  To put yourself on the waitlist for an intake appointment, please fill out the form below.

After submitting the form, expect a follow up message within 2 to 3 business days.  

I do not offer MDMA or psilocybin therapy in my private practice.  These medicines are not currently legal and only available in the setting of clinical research trials.  I do offer ketamine-assisted psychotherapy, which can be effective for treating depression, anxiety, and PTSD.  

If you're interested in finding out more or booking an intake appointment, fill out the form below.
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First Name *
Last Name *
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Email *
Mobile phone number
How did you hear about my practice?
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If you were referred by current therapist or provider, please share their name here:
In order to become a patient with this practice, it's necessary to be located in California during appointments.   *
While in person appointments may be available from time to time as needed, most appointments are by video.   *
There is currently a waiting list for new patients, and the next available appointment may be 2 weeks or up to 6 weeks away.  *
Practice information including fees is available at www.emilywillowmd.com/services

Please note this practice is not in-network with any insurance.  
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What type of treatment are you interested in?  (check all that apply). 

Please note that I do not offer MDMA or psilocybin therapy in my private practice.  These medicines are not currently legal and only available in the setting of clinical research trials.
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What are the main reasons you are reaching out right now?  *
Is there anything else you'd like to share, or any other questions you have that would help you decide if this is a good fit?
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