If in crisis dial or text 988

Request An Appointment

We look forward to seeing you!

We are committed to helping you find the right therapeutic fit. If at any point it does not feel like the best match, we will gladly help connect you with another therapist better suited to your needs.

Appointment Form Simple

First Name of Person Requesting Appointment

Last Name of Person Requesting Appointment

Email Contact

Phone/Mobile

A agree to receiving text messages and/or phone calls from Jill Smith and Associates

Age

Date of Birth

This appointment is for:

Child’s First Name

Child’s Last Name

Child’s Age

Date of Birth

Preferred Location

Briefly, tell us how we can help you?

Payment Source

Please note, there is a slight service charge when paying with a credit card

Medicaid Number

Consent Agreement

You will be asked for a credit card to hold your appointment. You will be charged using this card for your appointment if it is not kept.

Please note we do not accept insurance.

We can happily give you a superbill for possible insurance reimbursement.

Our session fees range from $150 to $250, depending on each therapist’s experience and licensure level.

We also offer reduced-rate sessions with a master level clinical intern

I have read the above and consent to hold my appointment