APPOINTMENT REQUEST

Please complete this form if you are interested in working with Dr. Dutcher.

Name *

Email address *

Phone number

What is your primary reason for seeking therapy? *

Have you previously received any form of therapy?

Are you hoping to use insurance to assist in paying for sessions? *

Please select at least one option.

Yes

If so, please list the insurance provider below.

What is your preferred method of communication? *

Please select at least one option.

Phone

Text Message

What is your availability for therapy sessions?

Is there anything else you would like us to know?

Additional questions or comments

Please confirm that you are not a robot.

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Susan Dutcher, PsyD, LP, LCMFT