New Client Screening

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Dawn Womack Michael

Please note that all therapy sessions are virtual. Please fill out and submit the form below and we will contact you as soon as possible to let you know if our services would be a good fit for you. We currently have openings 8am-2pm with a waiting list for appointments after 3pm. We do not expect to have openings after 3pm until the fall. We work with children and adults, 12 years old and up who live in Louisiana or Texas.

Name of potential client

Age of client or date of birth

Email address (guardian's email if potential client is a minor)

Name and relationship of person completing form

Reason for seeking counseling

Phone number (guardian's phone number if potential client is a minor)

How would you prefer to communicate

Text (fastest response)

Method of payment

Private Pay

Aetna Commercial

Blue Cross Blue Shield

Cigna

Humana Commercial

United Healthcare/Optum Commercial

UMR (Louisiana)

Other

How did you hear about us

Internet Search

Google Search

Referral from a friend

Referral from a professional

Psychology today

Insurance company website or directory

Select an option

I understand that all sessions are via telehealth

I am not interested in telehealth. Please disregard this submission.

Select an opton

I understand that all appointments will be between 8am-2pm.

I can not make appointments between 8am-2pm. Please disregard this submission.

Thank you for submitting your information! Our office will contact you as soon as possible.

Dawn Michael

dawn@dawnmichael.com

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