Request an Appointment

You are the most deserving person of your own love and care!

Please complete the following information and you will receive an email shortly!

Patient

First Name

Last Name

Patient Date of Birth

YYYY

(If minor patient, enter parent's email)

Patient Phone

(If minor patient, enter parent's phone number)

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What therapy services are you interested in?

(select all that apply)

Individual therapy

Couples therapy

Family Therapy

In Person or Telehealth (video)

Please choose your preference

Which Location?

Is the patient listed above under the age of 18?

Availability

(Please indicate a range of days and times you are available)

Are any family members currently seeing one of our providers?:

If yes, please let us know which provider(s):

If the patient is not the primary cardholder on the insurance provided (If applicable), please complete for the cardholder’s:

First Name

Last Name

Cardholder's Phone number

(###)

###

####

Cardholder's Date of Birth

YYYY

Cardholder's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relation to patient (Parent, legal guardian, spouse, etc)

Name of Individual completing this form

First Name

Last Name

If patient listed above is under the age of 18, Please provide both parents full name, phone numbers, emails, and address if different than patient

If you wish for your minor child's therapist to also have your child's email and/or phone number (for homework, resources, messaging) please add as well

Is there anything else you want us to know?

(If you have a specific clinician you wish to see or preferences, please enter here)

Once you click Submit, be on the lookout for an email response from INFO@HEALINGHARTZE.COM

Please note: *Regardless of marital status, we appreciate having both parents involved in a child's care and therefore request both parents' contact information unless legal documentation showing proof of sole custody and decision-making is provided. If providing the information for the other parent is not possible, please provide a statement explaining why this is not possible. *Requests for information regarding your insurance or coverage may take time to process. If you have specific questions about coverage after your patient profile is created and your insurance is processed, please ask to be put in touch with our Billing Department or contact your insurance directly* Thank you, and please keep on the look out for our email soon!