Schedule Change Form

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If you're an existing client whose availability has changed, please let us know below!

Email *

Name, first and last: *

Name of the Patient (if you're filling this out for a dependent) first and last: *

Patient Date of Birth: *

YYYY

Phone/Text Number we should use for scheduling and appointment reminders: *

Please indicate how you'd prefer to be reminded of your upcoming appointments: *

I prefer text reminders

I prefer email reminders

I prefer email AND text reminders.

We're in the office Mondays, Wednesdays, and Thursdays from 8am to 8pm. Click below to select the blocks of time that you are most likely to have availability for a session with Dr. Kennedy: *

Mornings : 8am-11am

Afternoons : 12pm-4pm

Evenings: 5pm-8pm

Unavailable all day

Mondays

Wednesdays

Thursdays

How often would you like appointments? *

weekly

every two weeks

monthly

Please let us know the date this schedule change will take effect: *

YYYY

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