Waitlist Waitlist for Client Waitlist Please fill out the following information completely and as accurately as possible. Once we receive your submission, we will be in touch with next steps. Name*Name of client First Last NameName of person filling out form (if different than name of client) First Last Phone*Enter the number you would like to be contacted atEmail*Enter the email address you would like to be contacted at Preferred method of contact*How would you prefer we reach out to you? Text Email Phone call What is this waitlist request regarding?*Please select what it is you are requesting to be placed on the waitlist for Individual Therapy (Please indicate which clinician in the next question) Group Therapy (Please indicate which group in the below text box; DBT, parental support, other) Supervision Whom are you requesting for waitlist?Please select who it is you are requesting to be placed on the waitlist for Catherine Jones Sarah Richards Grace Pardieck Leslie Donovan Clarissa Woolsey Kristina Akers Sarah Maness Tonya Thomas Aleena Prek Waitlist Info*Please indicate more information about the waitlist requestForm of payment* Self Pay Aetna Blue Cross Blue Shield Cigna Tricare United Health Care/United Behavioral Date* MM slash DD slash YYYY Consent* I agree to being contacted in the above selected format. Δ
