Schedule Appointment

Person Referring Patient & Relationship to Patient

Patient's Name

Patient's Insurance Name and Policy Number (if patient is not the primary subscriber, please also add the name of the subscriber and their date of birth). If the patient also has secondary insurance, please include that below

Patient's Phone Number

Patient's Home Address (include City, State, and Zip Code)

Patient's Email Address

Does the patient have a history of suicidal or homicidal ideation? If yes, please explain

Patient's Preferred Days and Times For Appointments

Overcoming Life's Obstacles Counseling

Scheduling an Appointment

Please complete the form below and
we will contact you to further discuss your referral and schedule an intake appointment.

Scheduling an Appointment

Please complete the form below and we will contact you to further discuss your referral and schedule an intake appointment.

Please complete the form below and
we will contact you to further discuss your referral and schedule an intake appointment.