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:
______________________________________________________
Schedule an appointment for myself
Your gender:
Your 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.
______________________________________________________
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):
______________________________________________________
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.
______________________________________________________
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
Lisa M. Hardebeck, Ph.D.
Olympia Psychology Services
2120 State Ave. NE, Suite 219A
Olympia, WA  98506

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

Dr. Hardebeck's email: lhardebeck@olypsych.com