join AMELIA INNIS’ waitlist

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

DAILY AVAILABILITY (CHECK ALL THAT APPLY) *

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

TIME AVAILABILITY (CHECK ALL THAT APPLY) *

Morning (8am-10am)

Late Morning (10am-12pm)

Mid-Day (12pm-2pm)

Afternoon (2pm-4pm)

Late Afternoon (4pm-6pm)

Evening (6pm - 8pm)

How long are you willing to wait on a waitlist? *

I’d like to be seen ASAP, even if it means seeing someone else

I’m specifically waiting for this therapist and can wait a few weeks

I’m comfortable waiting 1–2+ months to work with this therapist

I’m flexible and open to whatever timeline is needed