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 appointments are held M-Th at 10 am - 3 pm EST. Insurance: I understand that the full fee will be due at the time of service, and that I may choose to submit to my insurance for Out of Network (OON) reimbursement. We are not Medicaid/Medicare providers, and Medicare clients will be fully self-pay.Cancellations: I am aware that appointments can be cancelled without rescheduling twice per 6-month period with 48 hours notice, and that I can reschedule appointments even on short-notice. Fees: I am aware of the fees for service, which are $300* for 45-50 minute appointments and $395 for the 75-90 minute diagnostic evaluation. *Reduced fee options may be available if requested.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form