New Patient RequestsIf you are interested in making an appointment, please complete this form and we will be in touch as soon as possible! Click Here New Patient Requests Patient Name * First Name Last Name Name of Person Completing This Request * First Name Last Name Relationship to Patient * DOB and Age of Patient * Phone * (###) ### #### E-mail * Can we leave a voicemail or send an email at the contact information provided above? * What services are you interested in? * Please check all that apply. Individual Teletherapy Couples/Marital Teletherapy Family Therapy What are the issues you are wanting to address? * (Please check all that apply.) Anxiety Behavioral Problems Communication/Social Challenges Depression Infidelity Obsessive Compulsive Behaviors Military life stress Trauma ADHD Bipolar Disorder Other How did you learn about Reunion Health? * What company do you use for insurance? * If you are choosing the out-of-pocket route, are you aware of and do you accept the $150 per hour self-pay rate? * Yes No N/A Are you aware that we only provide teletherapy services and do not offer in person counseling services? * Yes No What state do you currently reside in? * These are the states we are currently able to offer services in. To learn which clinicians are licensed in each state, please refer to the "Team" page, then click on each clinician's bio to learn which state they are licensed in. South Carolina North Carolina Georgia Connecticut Florida Maryland Are you or your child currently experiencing any safety concerns? * (Suicidal ideations, suicide attempts, self-harming behaviors, or hospitalizations for suicidal behaviors.) Is there a specific day of week and time of day that would work best for your availability? * Do you have a preference in which counselor you'd like to work with? * Nicole Sinnigen (SC, NC, GA, CT) Barbara Wagner (SC, CT) Kellie Swofford (SC, NC) Kristal March (SC, FL, NC, CT) Kelly James-Fraser (GA) Ashley Wilson (SC, MD, CT) No Preference Thank you for your request.Nicole will be in touch soon! General InquiriesFor all other inquiries, please complete this form and we will be in touch as soon as possible! Click Here General Inquiries Name * First Name Last Name Profession * Phone * (###) ### #### Email * Subject * Message * Thank you for your request.Nicole will be in touch soon!
