AMI's Consultation Form

Welcome to AMI's potential client email page. Dr. Wilson is happy to correspond with you about any question or concern you might have before deciding to come in for a consultation. All information provided will be seen only by Dr. Wilson.

NOTE: If you have not already done so, please review AMI's fee structure before filling out this form. To avoid misunderstandings, please be aware that AMI does not accept medical insurance of any kind. If requested, AMI will provide a "super-bill" for clients whose PPO's allow out of network providers and might reimburse some of your cost, but AMI does not directly interact with insurance companies for any reason. AMI is a private pay facility, and fees are paid in full by the patient (or some related third party) before services are rendered.

How Did You Find AMI?:
First Name(s): *
Last Name: *
What Is Your Age?:
What Is Your Relationship Status?:
How Many Children Do You Have?:
City: *
What Type of Therapy You're Interested In?:
What Email Should Dr. Wilson Respond To? *
Please Re-Enter Your Email Address:: *
Why are you seeking therapy? Please be as specific as possible: *	Enter comments here!