Appointment Request Please complete the form below to request an appointment. I will be in touch as soon as possible to schedule. Thank you! Name (required) E-mail address (required) Phone number Preferred time and date for your session Referral Source (if applicable) What is this appointment for? Assessment / EvaluationTherapy SessionOther / Unsure Message To Haley By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "send" you agree to hold Haley Neidich LCSW LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.