Name*:

Phone Number*:

E-mail Address*:

Which therapist would you like to work with?*
---Madeleine ShaverKristin BroderickCharita SmithJanis EllingtonKristen DickensKale CooperDanielle Van WagenenBrittany BattistaRebekah ThompsonChacana GauldenTherapy and Medication ManagementMedication Management OnlyNo Preference

Would you also like to work with Ashley Lewis for medication management?
NoYes

For whom are you requesting the appointment?
MyselfMy child

If appointment is for a child (age 17 or younger), please list legal guardian(s):

* *Please note only legal guardian(s) can schedule appointments for minors and give consent to treatment.

Briefly let us know what lead to your decision for therapy*:

Name of insurance company, if applicable:

Are you a GA Resident?*
YesNo

Are you a FL Resident?*
YesNo