Appointment Change Request

Appointment Change Request

Not for Day Treatment, ABA, or Group Services
If your appointment is within one (1) hour, please call Client Services at 612-767-7222
Client Name *

First Name Last Name
Client DOB *

Month Day Year
Clinician Name
Location *
Service Type *
Appointment Details *

Month Day Year
Date
Time Minutes AM/PM Option
I would like to: *

Convert existing appointment to telehealth at the same date/time (preferred) Request to reschedule appointment to another appointment date/time Cancel appointment
I would like to: *

Request to reschedule appointment to another appointment date/time Cancel appointment
Note: request to reschedule is not guaranteed and is subject to appointment availability
Person Completing the Form: *

First Name Last Name
Relationship to Client *
Email Address: *
example@example.com
Preferred phone number *
Email Insert
CANCEL

CANCEL
CONVERT

CONVERT
RESCHEDULE

RESCHEDULE
Should be Empty: