Request Services

NOTE: The purpose of this form is not to address immediate and urgent needs. If this is an emergency, please dial 911 or go to the Emergency Room. Please do not use this for urgent medical or mental health needs as we will not be able to respond accordingly. Thank you. However if you have questions about this form, please call our office at (605)348-6500.

Personal Information

First name
Last name
Your email
Date of Birth
Age
Contact Name
Referred by
Primary Phone #
OK to leave a Message? YesNo
Street Address
City State Zip
Please describe your main concern in seeking an appointment

Service you are seeking Individual TherapyCouples TherapyFamily TherapyTesting / Assessment
Provider you prefer to schedule with No PreferenceMargaret D. Kelsey, Ph.D.Jennifer Kozel, Ph.D.Trisha T. Miller, Ph.D.Lynette R. Quast, Ph.D.
Preferred method of payment InsuranceSelf-Pay

Please note: This request does not guarantee services. Your concerns and provider availability will be considered in a review process, but are not guaranteed.

Insurance Information

Insurance Co
Ins Co Phone
Policy Holder Name:
Group Name:
Plan ID#:
Group No
Your Signature

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