Fuller

Request an Appointment

Please complete this form to request an appointment with Dr. Amy Fuller, LMFT, LPC or call (832) 848-0870.

First Name*

Last Name*

Phone*

Email*

How did you find Dr. Amy Fuller*

If you are comfortable, please provide the name of the person who referred you to Dr. Fuller:

I'm interested in:*

Your Message:

Preferred Date and Time

Dr. Fuller sees patients from 8 am to 3 pm Monday through Friday.

Parent or Guardian Name*

Parent or Guardian Phone #*

Parent or Guardian Email

Check here if Parent or Guardian Address is different from Client Address

Parent or Guardian address

Client Name*

Street Address*

City*

State*

Zip Code*

Spouse Name*

Spouse Phone

Spouse Email

Anniversary date

Please check here if spouse address is different than client

Spouse address

Curious if your health care plan will cover counseling? Therapy is covered by most health insurance plans. To find out what the insurance will cover prior to the first appointment, please complete the information below regarding your insurance plan. Dr. Fuller’s office will get back to you within 3 business days to let you know what the coverage will be for out-of-network mental health care. Dr. Fuller or her staff will discuss the coverage before sending in a claim to the insurance company.

Would you like to use your health insurance*?

To skip completing the insurance information check here.

Insurance Verification Information

Insurance Company Name*

Name of Insured*

Insurance Member ID*

Group Number

Insurance Phone Number for Customer Service or Behavioral Health*

Client's Date of birth*

Client's Social Security Number

Gender of client*

Male Female

Comment:

Please provide any additional information. If you have another insurance through a spouse or family member please submit a separate form.

By submitting this HIPAA Compliant Secure Form, I am giving permission to Dr. Amy Fuller and her office staff to contact me or those listed above with the information provided. I am aware that email, telephone and text are not secure, private methods of communication.
YOUR PRIVATE HEALTH INFORMATION WILL BE KEPT COMPLETELY CONFIDENTIAL. Any insurance information provided will be for the sole purpose of determining eligibility of benefits for therapy.

I would like to receive email from Amy Fuller PHD with resources for improved relationships and mental health. I would not like to receive email from Amy Fuller PHD unless it is direct email related to my therapy. (All email will be sent through HIPPA compliant secure email system). I do not wish to receive email from Amy Fuller PhD.