Appointment Request SNS

New Patient Inquiry

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?

Date / Time

Date

Question Title

* 3. How did you find me?

Another website (ie. Psychology Today)

Referred by your healthcare provider

Referred by one of my current or former patients/clients

Other (please specify)

Question Title

* 4. Which of the following best describes how you intend to obtain 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 or credit card)

Other insurance or payment form (please specify)

Question Title

* 5. 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

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

Psychopharmacology (aka Medication Management)

Counseling/Psychotherapy

Psychotherapy, specifically EMDR Therapy

Cognitive Behavior Therapy (CBT) and/or Mindfulness Based Therapy

Other (please specify)