Wicker Psychotherapy | Secure Scheduling Form

Secure Scheduling Form

Please complete this multi-page form to schedule your first session.

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 your insurance card will be required on a subsequent page.

Please note that Wicker Psychotherapy is only offering telehealth sessions at this time.

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.

Are you over 18 years of age? *

Do you have any form of medical insurance (including Medicaid or Medicare)? * 🛈

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

Did you already provide your insurance information using our insurance card form? *

What is the name of your employer? * 🛈