Name *

First Name

Last Name

Date of Birth

Please share your DOB. Your personal information is never shared regardless of whether we work together. Your DOB helps efficiently establish your patient portal if we do enter into a care agreement.

MM

DD

YYYY

Cell Phone *

Please share a phone number that you consent to using for Megan to reach you.

(###)

###

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Please identify whether you are interested in individual or joint therapy: *

Individual

Joint

Please identify the type of clinical meetings in which you are interested: *

Meetings in office

Meetings via secure videoconferencing

Meetings while walking outside together

Availability for Appointments *

Please characterize your availability for appointments.

My schedule can be a stressor at times.

I have several blocks available each week.

My schedule can accommodate most appointments with notice.

My schedule is very flexible.

Other

Scheduling *

I consent to using text messaging for scheduling purposes.

I DO NOT consent to using text messaging for scheduling purposes.