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Blue Mountains
Blue Mountains

Appointment Request/Contact Me

Please answer the following questions in the form below under the "your message" area.  An appointment cannot be scheduled until these questions are completed.  I will get back to you within 24 hours.  Thank you!

* If you are using your health insurance, you may need to contact your insurance company in order to find out how they cover behavioral health.  It is often not the same as your medical coverage and is not usually listed on your insurance card.
  1. Name of Insurance company?
  2. Deductible Information? How much of your deductible have you met?
  3. Copay/coinsurance?
  4. Will you be using an EAP?  An authorization number will be required.
  5. What would you like to accomplish in counseling?
  6. Do you prefer telephone or video conferencing for appointments?
  7. Days and times you are available for appointments?

 

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

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By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.

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