Request New Client Appointment

Request for New Client Appointment

At this time, Christina only has openings for EMDR Intensive Therapy and Hypnotherapy. She currently has a 6-12 week wait list for new clients requesting individual therapy.

Name *

First

Last

Date of Birth *

Email *

Briefly state what brings you to therapy: *

Therapy service I am interested in (select one) *Individual Therapy EMDR Therapy EMDR Intensive Therapy Hypnotherapy I’m unsure, I would prefer a consultation

Benefits I will be using for therapy (select one) *Blue Cross Blue Shield of KansasAetna CommercialTricare WestSelf / Private PayHealth Savings Account (HSA) I am out of network (self-pay)

My Availability (select one) *I need an appointment ASAPI am flexible with my availability If no appointments, I am okay with a waitlist

Other information I would like Christina to know

I understand I will be contacted within 24-48 business hours after submission of form. Requests for new client appointments are accepted based on availability at the time of request. *

• Yes I understand

Submit