Appointments

TO SCHEDULE YOUR FIRST APPOINTMENT

For appointments, please complete this page so when we contact you within the next 24 to 48 hours, we will be prepared to schedule your appointment with a best-fit, available therapist.

By sending unencrypted email to us, you accept the slight risks of email breaches that may compromise your personal health information.

CLIENT INFORMATION

Client Name*

First Last

Client Date of Birth*

Address*

Street Address City State ZIP Code

Client Email*

Client Phone*

If client is a child, please fill out parent name, email and phone

Parent Name

First Last

Parent Email

Parent Phone

INSURANCE

Name of Insurance Company*

Name of Insurance Company

If you have your member identification number, check "Yes" and enter it below to have your coverage verified. If you do not have it, email it to byron@cedarcreekcounseling.com as soon as possible.*

Yes

Insurance Identification/Member Number*

Subscriber to Insurance*

Subscriber Date of Birth*

THERAPY

Name of Preferred Therapist

Please check all that may apply so our best fit therapist can contact you within 24 hours to schedule your first meeting

Other Concerns

Check all possible times you are available for meetings

7a to 10a

10a to 4p

4p to 8p

Saturdays 8a-3p

CAPTCHA

-Phone-

(262) 240-0299

Dr. Byron Bloemer – ext. 0
Bruce Semon, MD – ext. 0
Lilly Risch, MSW, LCSW – ext. 1
Cathy Ryan, LMFT – ext. 2
Kate Greenway, LPC – ext. 3
Dr. Melinda Somogyi – ext. 5
Ken Hartenstein, LPC – ext. 6

Dr. Liz Hansen (at Cedar Lake Counseling): 262.244.6177 x116

CLIENT INFORMATION

INSURANCE

THERAPY

-Phone-

(262) 240-0299

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