Request an Appointment

Contact Name:

E-mail address:

Mailing address :
(Enter the entire address on the line above - e.g. 123 Wherever Lane, Somewhere, TN 37919)

Telephone number:
This number is to your..      home       work      cell phone

Is the appointment that you are requesting for you (the person named above)? Yes or No
If the answer is "No," for whom is the appointment? Name:
How is the client who needs the services we provide related to you?: Select one below Son Daughter Step Son Step Daughter Foster Child Husband Wife Significant Other Father or Mother

When is the best time of day for us to set up an appointment for you? 

Morning (from 9:00 up to 11:00 a.m.)        Mid-day (from 11 a.m. up to 2:00 p.m.)    
Afternoon (from 2:00 p.m. up to 5:00 p.m.)     Evening (from 5:00 p.m. up to 7:00 p.m.)

Type of Appointment Desired (Select One): Clinical Counseling (Individual, Couples or Family) or

Psychological Testing or Christian Counseling or Equine Assisted Therapy or

Trauma / EMDR Counseling or Military Counseling or Educational Counseling (free)

Professional Staff Member Desired: Any Counselor Best Suited Dr. Sabine Scoggins Melanie Nordstrom, LCSW Tim (Educational Counseling)
Status of the Appointment: Initial Appointment or Follow-up Appointment

Which insurance plan is the person for whom the counseling is requested covered?
Name of Insurance Company:

Check here if you are requesting to reschedule an existing appointment.

If this is a rescheduling request, when was the original appointment that you wish to change?:
Day Monday Tuesday Wednesday Thursday Friday Saturday Date Time 9:00 a.m. 10:00 a.m. 11:00 a.m. 12:00 p.m. 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m. 5:00 p.m. 6:00 p.m. Other
With which of our staff was the appointment? Dr. Dimitroff (retired, no longer serving clients) Dr. Scoggins Tim (Educational Counseling) Other

Comments or Questions:

If you have a specific question or comment, it may be submitted in this section.: