Appointment Request SNS, updated

Professional Services Inquiry Questionnaire

This form must be submitted by the person who will be receiving services.
Requests made by a third party (family member, spouse, friend, or significant other) may not be considered.

Question Title

* 1. How do I get in touch with you?

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address

Phone Number *

Question Title

* 2. What is your date of birth?

Please, enter in the requested format

Date

Question Title

* 3. How did you initially find me?

I found you on your website

I found you from another website (ie. my insurance Provider Directory, Psychology Today, Healthgrades)

I am being referred by my current therapist or healthcare provider (please, complete Question 4)

I got your name from one of your current or former patients/clients (please, complete Question 4)

Other (please specify)

Question Title

* 4. Please, provide details of your response. (Name and Contact information of your current therapist/healthcare provider, insurance provider, or which specific website)

Question Title

* 5. Which of the following best describes how you intend to pay for services?

I intend to use Aetna Insurance

I intend to use Anthem BC/BS Insurance

I intend to use Cigna Insurance

I intend to pay for the services myself, without billing insurance (cash, check, or credit card)

Other insurance or payment form (please specify)

Question Title

* 6. What is your scheduling flexiblity?

I have considerable scheduling flexibility and can make myself available most of the time

I have limited scheduling flexibility and I have reviewed your posted hours and can make myself available at those times

I have very little flexibility in my scheduling

Other (please specify)

Question Title

* 7. I am interested in the following service(s)

Psychopharmacology (aka Medication Management)

Counseling/Psychotherapy

EMDR Therapy

Cognitive Behavior Therapy (CBT)

Mindfulness Based Therapy

Solutions Focused Therapy

Other (please specify)

Question Title

* 8. I would be willing to consider having one of these services provided by a capable and experienced student, under your supervision?

Yes