If you would like to be added to a clinician waiting list, please fill out your information below. You will be contacted with confirmation of your status on the waiting list.

First Name *

Last Name *

Client Date of Birth *

If you are requesting the appointment for someone else, what is your full name and relationship to the client? Please be sure the client's name is listed at the top of this form.

Phone Number *

May we text you? By selecting Yes, you consent to receive SMS messages from Cardinal Psychotherapy & Coaching. Message and data rates may apply. SMS Terms: www.cardinalpsychotherapy.com/sms-terms *

Yes

No

Email *

Type Your Email Again *

State *

If you have a specific therapist you are interested in, choose them below? *

Who is your second choice for a therapist?

Do you prefer in person or virtual sessions? *

Name of Primary Insurance Company *

If your insurance is not listed above, enter it below:

Please provide a brief summary of what services you are seeking, the days and times you are available, or any other questions you may have. *

Please verify your request *

Join a Waiting List

If you would like to be added to a clinician waiting list, please fill out your information below. You will be contacted with confirmation of your status on the waiting list.