Wicker Psychotherapy | Secure Scheduling Form

Secure Scheduling Form

Please complete this multi-page form to schedule your first session. Please note that Wicker Psychotherapy is only offering telehealth sessions at this time.

If you plan to pay at least partially with insurance, you may find it easiest to complete this form on your smartphone as photos of the insurance card are required.

Your First Name *

Your Last Name *

What are your pronouns? *

Your Email Address * 🛈

Your Phone Number * 🛈

Please acknowledge that emails and text messages should not contain sensitive information. * 🛈

I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.

Do you plan to pay for your sessions at least partially with insurance? * 🛈

What is the name of your employer? 🛈