Parent/Guardian Consent for Psychotherapy

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Contact Information

319-853-8762

scheduling@evergreentherapycenter.com

North Liberty Office
595 Ashley Court, Ste 5
North Liberty, IA 52317

Cedar Rapids Office
375 Collins Road N.E., Ste 103
Cedar Rapids, IA 52402

Hours of Operation

Monday 9AM – 5PM
Tuesday 9AM – 5PM
Wednesday 9AM – 5PM
Thursday 9AM – 5PM
Friday 9AM – 5PM

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Evergreen Therapy Center

Request for Therapy Session

I am interested in a therapy appointment with Christine Topping

Name

Email

How did you hear about us?

Psychology Today Google Search Bing Search Referral from a healthcare provider Other

Preferred Location

Cedar Rapids Office North Liberty Office Telehealth

Insurance

Wellmark or Blue Cross Medicare only (no supplemental) Medicare + Supplemental Medicare Advantage (Medicare offered by a private company) Midlands Choice, Health Partners and Cigna. Out of pocket Other coverage

Phone

What is the best way to contact you?

Text message (you'll receive a text from (319) 853-8762) Email (you'll receive an email from eunice@evergreentherapycenter.com) Phone call (you'll receive a call from (319) 853-8762) Any of the methods above

Your Request