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Westmoreland Psychotherapy Associates

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Getting Started

Please complete the form on this page to request an appointment.

Once you contact us, one of our trained client care coordinators will be in touch to help schedule an appointment with you as quickly as possible.

Please Enter Your Contact Information

First Name

Phone

Last Name

Email

Who are you completing this form for? *

Myself

Other

If Other, please specify the name of the person you are completing this form for:

If this person is a minor, how old are they?

Tell us about your reason for contacting us

Please let us know what brings you here today?

Please select all symptoms and issues that apply:

Issues

Depression

Anxiety

Anger Management

ADHD

PTSD

Trauma

OCD

Panic Attacks

Post Partum

Bipolar Disorder

Eating Disorder

Bullying

Other Issues

Stress Management

Life Transition

Caregiver Fatigue

End of Life Challenges

Grief & loss

Adoption Related Concerns

Family of Origin Issues

LGBTQ+

Identity Persecution

Self Esteem

Midlife Challenges

Behavior Management

Other Issues

Substance Abuse and Addiction

Non Substance Use Addiction

High Functional Autism

Issues Related to Faith

Self Harm

Chronic Illness or Chronic Pain

Somatic Symptoms

Divorce

Sexual Disorders

Poly Relationships

Sex/Positive Kink Aligned

Other, please specify

Address Information

Street Address

Strreet Address Line 2

City

State

Postal / Zip code

Health Insurance Information and Payment Options

What health insurance or payment options do want?

Insured Member ID Number (Located on the front of you insurance card, not your group id)

Subscribers Name (If different than member)

If Other, please specify

Member Date of Birth

Subscribers Date of Birth

Do you have a secondary insurance?

What secondary insurance do you use?

If Other, please specify

Secondary Insurance Member ID Number

Subscribers Name (If different than member)

Secondary Insurance Member DOB

Secondary Insurance Subscribers DOB

Your Availability and Preferences

What is your availability (days and times)?

Do you have a preferred Practitioner?

Choose you preferred method of communication

What type of sessions do you prefer?

Thank you for submitting your information.

Our team will review your information and contact you shortly.

Copyright 2023, Westmoreland Psychotherapy Associates

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