Anxiety & OCD
Treatment Center
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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?
Select one...
Neither
Medicaid
Medicare
Both
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 - 4 pm EST.
I understand that the full fee will be due at the time of service, and that I may choose to use my Out of Network benefits for partial reimbursement (if I have a PPO plan with OON benefits).
I am aware of the no-cancellation (flexible reschedule) policy, which allows me to reschedule even on short notice to the week before, during, and after the missed appointment.
I am aware of the fees for service, which are $300 for standard appointments (45 minutes) and $410 for the diagnostic evaluation (75 minutes).
Thank you! Your submission has been received!
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