New Client Waitlist — Katie Vines, LPC

Request a new client appointment

I currently have a small waiting list for new clients. If you are interested in becoming a client please fill out the form below. Make sure to include your email address as that is how we will contact you regarding scheduling. Thank you so much for your patience and for your interest in my practice!

Name

First Name

Last Name

Client's Email

Client's Phone Number

(###)

###

####

Date of Birth

MM

DD

YYYY

If you feel comfortable doing so, please give a brief explanation of why you are seeking counseling

Who referred you to Katie?

Filing Insurance? If YES please fill out information below.

Name of Insurance Company

Insurance Policy Number

Insurance Group Number

Insured's Name (if different from client)

Insured's Date of Birth

MM

DD

YYYY

Insured's Address

Request a new client appointment

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