Contact and scheduling

>> Unfortunately, I am currently full and do not have openings for ongoing appointments. << 

Depending on your availability for appointments, a spot could open up soon, but unlikely prior to July 2019. Please complete the form so that we can start the communication process despite the lack of available times. I may be able to make suggestions, referrals, etc. I have this form here to manage expectations about availability; but things are often changing and thus the schedule is not predictable. Without a completed form, I won’t know that you’re looking for support when a spot opens up.

Waiting list form

Please complete this form and I’ll be in touch within 72 hours

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Name
Name
Phone
Phone
How did you hear about me? *
Please check off all times and days you are available for an ongoing appointment *
This will help me plan ahead and schedule you as soon as I can. If you don't see a window of time that works for you, it is likely that I do not currently have hours at that time. I do not currently have evening hours.
Please select your method of payment for services
Please look carefully at the insurances below. *Independence Blue Cross/Personal Choice and Keystone Health Plan East are not the same as Blue Cross/Blue Shield.
Preferred methods of contact
I’m looking to connect with you about:
Symptoms
{Optional} Please check of symptoms you are experiencing:
I'm looking for the following services:
Check all that apply
What do you hope will be different? What will have changed?
Emergency *
I understand that if I am having thoughts of harming myself that I need to call 911 or go to my nearest emergency room. This form is not a consent nor a guarantee for treatment.
Please include any other information you feel is important for me to know.