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. 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.I am aware of the flexible reschedule policy, which allows me to reschedule even on short notice to the week before, during, and after the missed appointment. Two "freebie" cancellations are given per 6-month period with at least 48 hours notice.I am aware of the fees for service, which are $300* for 45-50 minute appointments and $410 for the 75-90 minute diagnostic evaluation. *Reduced fee options are available if requested.

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