Currently not able to accept new clients due to full caseload.

We sincerely apologize for the inconvenience.

New Client Waitlist Request Form

If you would like to be placed on a waitlist for a future new client opening, please be aware that wait time may take at least 4-6 months or longer, depending on availability and queue. Morning appointment times become more available. Afternoon openings are rare.

If you would like a referral, please email Hello@marybmooretherapy.com.

Thank you!

Your Name

Parent or Guardian

First Name

Last Name

Your Email

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Child's Name

First Name

Last Name

Female

Male

Date of Birth

MM

DD

YYYY

Current School and Grade

I am seeking...

Therapy for my child (age 3-14)

Parenting for myself

Social Skills Group for my child (K-6th grade)

Other (describe below)

What brings you to therapy at this time? What are your therapeutic goals?

How did you hear about me?

Please read and check:

I acknowledge that Mary B. Moore, LCSW PLLC is a self-pay practice and does not take insurance. Full payment will be due at time of service. A SuperBill is available upon request for clients to file for out-of-network reimbursement with their carrier.

Need support or help with scheduling or your client portal? Email Britny, my Client Coordinator
hello@marybmooretherapy.com

Questions? Email me
maryb@marybmooretherapy.com