Get Started - Complete the New Client Inquiry Form

New client inquiry

If you are interested in pursuing treatment or have questions, please complete the form below.

First Name:

Last Name:

Email:Phone:Age:State located in:Reason for seeking services:
Please describe the concerns that bring you to therapy (be specific) and what you are looking for in treatment or in a provider.
How did you hear about the Anxiety & OCD Treatment Center?
Who referred you (personal contact or provider), or if not referred, how did you learn about this practice?Do you have Medicaid/Medicare?Have you had any aggressive behavior towards yourself or others within the past year? (e.g., related to suicide, non-suicidal self-injury, violence)
Please explain, such as how often and when the last time was.
What interested you in our services specifically?
Additional comments or questions:I am aware that Dr. Stebbins is available for appointments M-F starting between 9 am and 2 pm EST. I acknowledge that Dr. Stebbins does not directly participate with insurance, that I will be paying the full fee at the time of service, and that I can choose to submit for Out-of-Network reimbursement through my insurance if I would like.I am aware of the reschedule-only policy, which permits me to reschedule (not cancel) appointments to the week of the missed appointment with 24 hour notice, and 3x/year on short-notice.

Thank you! Your submission has been received!

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