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?Clinician preference:Have you had any thoughts of harming yourself or others in the past year? Any history of suicide attempts or preparatory behavior, self-harm without the intention of dying (NSSI), or aggressive behavior? 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 of each clinician's appointment schedule: Dr. Oxana (M-Th, 10-3 CST) and Dr. Sisemore (Tue 2-5 & Wed 8-11 CST). 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 minute appointments and $395 for the 60-75 minute diagnostic evaluation. *Reduced fee options may be available if requested.

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