Request appointment | Janice Eickholt-March LMSW CADC

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

Why are you seeking therapy at this time?

Outpatient Psychotherapy

What mental health concerns or treatment have occurred in the past?

Referral source

Enter how you were referred to our services

Self referred Probation/Parole requirement Doctor/psychiatrist/primary care referral Other

Payment method

How do you plan to pay for services?

Please list any current medications and doses below

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Who is your primary care doctor? Enter n/a if you do not have one

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Who is your psychiatric provider? Enter n/a if you do not have one