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 * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming 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 No Done