You may use this form to request an appointment, cancel an
existing appointment, ask a question, or make a comment:
Your first name:
Your last name:
Your email address:
Your phone number:
I would like to:
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Schedule an appointment for myself
Your gender:
Your birth date (mm/dd/yy):
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Preferred day/time for
appointment (you may select
more than one option by
holding down the Ctrl key):
Insurance information - providing insurance information now is
optional, but may help to expedite scheduling:
Subscriber ID number:
Group number:
Insurance company's
customer service phone number:
Your mailing address:
You may explain the reasons for this appointment below.
______________________________________________________
Schedule an appointment for my child
Child's full name:
Child's gender:
Child's birth date (mm/dd/yy):
Payment method:
Preferred day/time for
appointment (you may select
more than one option by
holding down the Ctrl key):
Insurance information - providing insurance information now is
optional, but may help to expedite scheduling:
Subscriber ID number:
Group number:
Insurance company's
customer service phone number:
Your mailing address:
You may explain the reasons for this appointment below.
______________________________________________________
Cancel an existing appointment
A full session fee will be charged for appointments canceled with less than
48 hours notice.
Client name:
Appointment date:
Would you like to reschedule?  (Y/N):
Preferred day/time for
rescheduled appointment (you
may select more than one option
by holding down the Ctrl key):
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Explain the reason for my appointment request; ask a
brief question; or make a comment
Use the space below to ask your question, or give a brief
description of the reasons for this appointment. You may
also use this space to clarify any other information you
have submitted on this form.
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I would like Dr. Hardebeck to  respond to this message (check one):
no response necessary
by email, at the address above
by telephone, at the number above
Olympia Psychology Services
2120 State Ave. NE, Suite 219A
Olympia, WA  98506

Phone: 360-539-8916       FAX: 360-539-5938

Click here to contact Dr. Hardebeck directly
Click here to contact Dr. Zimmerman directly

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