Your Name *

Phone *

I am scheduling for:

Child's Full Name

How do you prefer we contact you? (check all that apply) *

Text

Phone Call

Concerns to address in therapy:

I am interested in:

In-person

Telehealth

Either

Insurance Company Name

I am interested in scheduling with the following:

How did you hear about our practice?

Please pick a date and time below to reserve your phone appointment before submitting this form. If you do not, it will not be reserved.

Messaging Consent

By providing your phone number, you agree to receive text messages from Eating and Behavioral Health Associates. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.