APPOINTMENT REQUEST

Please complete this form if you are interested in working with Dr. Dutcher.

Name *

Email address *

Phone number

What is your preferred method of communication? *

Please select at least one option.

Phone

Text Message

Which location do you prefer? *

Please select at least one option.

Wichita (240 N Rock Rd)

Mulvane (1204 SE Louis Dr.)

Televideo

What is your primary reason for seeking therapy? *

Have you previously received any form of therapy?

Are you hoping to use insurance to assist in paying for sessions? *

Please select at least one option.

Yes

If so, please list the insurance provider below.

What is your availability for therapy sessions?

Please confirm that you are not a robot.

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Susan Dutcher, PsyD, LP, LCMFT