Office

Branch Psychological

Tel: 407.205.9855

scheduling@branchpsychological.com

2601 Wells Ave

Ste 121

Fern Park, FL 32730

New Client Consultation Request Form

To request a pre-therapy consultation with Dr. Branch, please complete and submit this form. You can expect an initial response via email within 3-5 business days, so please keep an eye on your inbox (and spam folder, just in case).

Which formats for therapy are you seeking? (Please check ALL that apply) * Required

Individual Therapy (in-person)

Individual Therapy (by video)

Couples Therapy (only provided in-person)

EMDR (in-person)

EMDR (by video)

Somatic Therapy (in-person)

Somatic Therapy (by video)

Do you want to use insurance? (NOTE: insurance can only be used for individual therapy.) *

No, I will pay out of pocket

Yes, I have Aetna

Yes, I have United or Oscar or Optum

How did you find me? *

Google search

Psychology Today

Provider Directory through insurance

EMDRIA.org Provider Directory

Referral from another provider

Referral from a friend/relative

Somatic Experiencing Provider Directory (traumahealing.org)

Which day(s) of the week and times of the day are you available to attend sessions? Dr. Branch's hours are usually 10am to 5 or 7pm Mon, Tues, Thurs, Fri.

(Optional) Please use this box if there is anything else you would like to share at this time. If you were referred to Dr. Branch by a specific person or place, please mention this in your message.

Thanks for submitting! Please visit your inbox for an instant email that contains helpful information for you about this process and next steps.

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