Wait-list Request
Thank you for seeking services with Simplicity Psychotherapy, LLC. If you received this form, your preferred therapist does not have slots for immediate openings, but is likely to have availability in the future.

Please note that completing this form will allow us to consider you for sessions with anyone on the team, so if you have a preferred therapist be sure to select that name below. Due to the nature of the counseling we provide, counseling spaces fill up fast and we cannot predict or guarantee when booking slots may become available. As a result, we cannot provide timelines for wait list times at this moment.

Please note that a member of the team is closely monitoring the waitlist to ensure that all persons are serviced in a timely manner.  

Sign in to Google to save your progress. Learn more
Name *
Email *
Phone *
Zip Code *
Briefly state what brings you to counseling at this time? *
Preferred Therapist
Would you be willing to meet with a therapist in training? *
What type of service are you seeking? (Mark all that apply) *
Required
How soon would you like to schedule an appointment?
MM
/
DD
/
YYYY
How did you learn about our counseling practice? Specific person or website appreciated. *
How urgent would you rate your need for services? *
Not At All Urgent
Extremely Urgent
I understand that Simplicity Psychotherapy is a private pay practice that does not directly bill insurance companies. *Please contact the office at 404.940.1582 with any questions about insurance. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Simplicity Psychotherapy. Report Abuse
Google Forms