AVAILABILITY NOTIFICATION FORM
Thank you for your interest in treatment!  
​*Please note that all of our providers currently have WAIT-LISTS for treatment.

You may fill out our "AVAILABILITY NOTIFICATION FORM" below if you would like to be added to our waitlist. 

Scheduling varies based on clinician availability, as well as patient flexibility in scheduling. Afterschool timeslots are in highest demand, and there is often a several month wait to start treatment for higher-demand times. If you have flexibility in scheduling and/or are open to telehealth services, treatment can often start sooner.

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

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.
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Name of Patient
Today's Date / Date of INQUIRY (not DOB)
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Age of Patient
Sex of Patient
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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.
Brief description of presenting problem/concerns:
Due to demand for services, several of our providers currently have WAIT-LISTS. 

Please indicate which providers you would be interested in seeing, when we have availability for new patients. (You may select multiple options). All of our providers have specialized training in OCD, Anxiety Disorders, O-C Spectrum Disorders, & Phobias. 

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. Be as specific as possible (e.g., anytime; 9-12pm; after 2pm) to help with scheduling. 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, or if you are located in an approved PsyPact state, due to Psychology licensing laws https://psypact.org/mpage/psypactmap
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Who were you referred by? If self-referred, please indicate so (or how you found out about us).
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 several of our providers currently have waitlists for new patients. This form will be used to notify you when we have new patient openings that fit with your availability.
*Please pursue referrals if you are in urgent need of care.
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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.                                                 
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