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Contact/

Appointment Request Form

Please fill out the following to request an appointment and reduce wait time for a response.

Name

Email

Phone, only if preferred contact

Service Type

Individual Adult

Individual Minor 10 and up

Couples/ Relationship

Emotional Support Animal

Evaluation only

Other

Meeting Preference

In Person Only

Telehealth Only

I'm open to both

Payment/ Insurance

Self Pay, no insurance

Self Pay, with documentation for insurance

Anthem

UHC

Aetna

Oscar

Oxford

Medicaid or Medicare

Other

Indicate your typical availability, select all that apply

Flexible/ varied schedule

Monday morning 9a-12p

Monday afternoon 1p-4p

Monday evening 5p or later

Tuesday morning

Tuesday afternoon

Tuesday evening

Wednesday afternoon

Wednesday evening

Thursday morning

Thursday evening

Friday afternoon

I have provided only secure, personal contact information, where I am safe and willing to receive a reply.

Thanks for getting in touch! Please look out for a reply from info@wavecrest.us

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