WAITLIST

Before signing up for the waitlist, please read the following information about the types of patients I see and the kind of treatment I provide.

This is for adults only, referring themselves. Do not fill this form out for someone else. There are no exceptions to this rule. Killington EAP employees, please call instead.

Once I have an opening, I'll notify you. Please respond within 24 hours to confirm the appointment. At that time, I'll send electronic paperwork to you. If I don't hear back from you within 24 hours, I'll remove you from the list.

If you find another provider in the meantime, please let me know so I can take you off the list.

I do not provide marriage/couples counseling or mandated treatment, e.g., DWI counseling, probation/parole, court-ordered evaluations, etc.

Teletherapy patients must be physically located in the only two states I am licensed in, Vermont and Ohio, at the time of our appointments.

Are you over 18?

Yes

First Name

Date of Birth

Are you filling this form out for yourself?

Yes

Last Name

Phone

Which contact method do you prefer?

Phone

Do you plan on using health insurance?

Yes

You're on the list.

Waitlist