New patient request

Name of Patient or Guardian *

First Name

Last Name

Phone *

(###)

###

####

If we are unable to reach you, may we text you to coordinate a time to talk?

Yes

No

Are there specific services you are seeking (check all that apply)?

Psychiatry (medication)

Psychological Testing

Psychotherapy/Counseling

Clinical Supervision

Organizational Consultation

Executive Coaching

Our doctors and therapists are in demand. We want to help as many people as possible and have limited time to do so. At Alliance we do not “overbook” our doctors/therapists and thus scheduling an appointment is a commitment. When you book your initial appointment a credit card will be required. Alliance will charge the full fee for any missed appointment unless the appointment is canceled or rescheduled with 24 hours or greater notice. *

I acknowledge

In order to provide the highest quality of services, ensure privacy and keep treatment decisions between you and your doctor or therapist, Alliance does not accept any form of insurance. Payment is required at the time service. Please see Service Fees under New Patients for details. *

I acknowledge