Client Portal - Stacey L. Salant, Ph.D., Licensed Clinical Psychologist

Appointment Request

Thank you for contacting Stacey L. Salant, Ph.D., Licensed Clinical Psychologist. Please fill out the information below to request your first appointment.

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If you cannot safely wait for a call back, please call 911 or head to the nearest ER.

Insurance:

Insurance Company Name:

Member #:

Group #:

Coinsurance (%):

Copay:

Submit

Cancel

Personal Information

Contact Information

Phone

Address

Provider:

Please explain the reason you are seeking help at this time:

Insurance