SCHEDULE AN APPOINTMENT

Please fill out this brief form and someone from our office will contact you shortly to confirm a time and date that works best for you.

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Todays Date

Todays date

YYYY

Time of Day that would work best for your appointment

Reason for Seeking Therapy

Who is your insurance carrier? ex. Blue Cross/Blue Shield, Health alliance, Aetna etc?

Any Questions? (not required)

Thank you for submiting your request. We will contact you as soon as we can.

You will be required to fill out paperwork at the start of your first counseling session. It may seem like a distraction, especially when you’re nervous, but it protects your rights, secures your consent to engage in therapy, and informs you about our policies.

Address:

2001 E. Main St.

Olney IL 62450

Phone:

618-354-0878