AVAILABILITY NOTIFICATION FORM
Thank you for your interest in treatment!  
​*Please note that all of our providers are either not currently accepting new patients, or have WAIT-LISTS for treatment.

You may fill out our "AVAILABILITY NOTIFICATION FORM" below if you would like to receive an email when we are accepting new patients. Due to demand for services, for individuals who are not already on our wait-list, we do not anticipate any new patient availability prior to March 2024. 

Scheduling varies based on clinician availability, as well as patient flexibility in scheduling. Afterschool timeslots are in highest demand.

Please pursue referrals if you are in urgent need of care. 

If you have questions about our practice, we encourage you to email us at info@jacobcenterforebt.com.

We also encourage you to check out our Frequently Asked Questions, which includes answers to commonly asked questions, accessible at: https://www.jacobcenterforebt.com/faqs.html

Please note that we specialize in treatment of OCD, O-C Spectrum Disorders, Anxiety Disorders, & Phobias. 

Due to the specialized nature of our practice, we are self-pay and do not take any insurance directly, although we'd be happy to provide you with documentation to help you submit for out-of-network benefits. More information about this can be found at the above link to our FAQ's.
Sign in to Google to save your progress. Learn more
Name of Patient
Age of Patient
Today's Date / Date of INQUIRY (not DOB)
MM
/
DD
/
YYYY
Sex of Patient
Clear selection
Brief description of presenting problem/concerns:
Please indicate which providers you would be interested in seeing? (You may select multiple options). All of our providers have specialized training in OCD, Anxiety Disorders, O-C Spectrum Disorders, & Phobias. 
*Currently, due to demand for services, all of our providers have WAIT-LISTS. 

Please click this link to learn about our providers: https://www.jacobcenterforebt.com/providers
Session Availability (Weekdays/Times). If completely flexible, please indicate so. *Note: Given that we see a large number of children & adolescents in our practice, after-school times tend to be most in-demand. We do not currently offer sessions on weekends.
Do you prefer sessions via telehealth, in-person, or it  doesn't matter?
*Note: Telehealth can only be provided when you are physically in the state of Florida, due to Psychologist licensing laws, unless your provider is an approved PsyPact provider and your state is in PsyPact. https://psypact.org/mpage/psypactmap
Several of our providers are PsyPact providers.
Clear selection
Who were you referred by? If self-referred, please indicate so (or how you found out about us).
Parent(s) Name: (if applicable)
Best Contact Phone Number (for Parent if patient is under 18). *If a parent is calling for a patient who is over age 18, you may list contact numbers for both a parent and the patient.
Best days/times to reach you by phone?
Email Address for Patient (if patient is over 18) or for Parent (if patient is under 18), if you would like for us to contact you via email.
Please check the below box to give consent for us to email you to discuss availability/scheduling.
Please indicate any additional notes, or list any questions we can answer for you.
Please confirm that you are aware that our practice is self-pay, and we do not take any insurance directly, although we'd be happy to provide you with documentation to help you submit for out-of-network benefits.
Please confirm awareness that all of our providers are either NOT currently accepting new patients, or currently have waitlists. This form will be used to notify you when we have new patient availabilility that fits with your availability, though we do not anticipate any new patient openings prior to March 2024. 
*Please pursue referrals if you are in urgent need of care.
Clear selection
Thank you for completing our new patient request form! We will be in touch within 1 week to confirm receipt of your inquiry, or if we have any questions. If you have any questions for us, we can also be reached via email at info@jacobcenterforebt.com, as that is the quickest way to get in touch with us. We can also be reached by phone at (561) 290-9080.                                                                                                                                                                                                                                                 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of jacobcenterforebt.com. Report Abuse
Google Forms