Dustyn Williams, LMHC | SimplePractice

Dustyn Williams, LMHC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

State

Select the state you live in

Reason for care

What kind of care is being sought?

Psych-Ed Consult for Recipients of Donor Gametes (Eggs or Sperm) Psych-Ed Consult for Recipients of Donor Embryos Psych-Ed Consult for Intended Parents via Surrogacy Psychological Evaluation to become Gestational Carrier Psychological Evaluation to become Egg/Sperm Donor Individual or Couples Psychotherapy

Brief description of fertility history, current treatment plans, and goals for session

Limited to 600 characters

Administrative

Referral source

Doctor, clinic, agency, or other who referred you

How would you like to be contacted to set up an appointment time?

Email Phone call Text message

If you are scheduling a 3rd party reproduction consult or eval, and are married or living in a committed relationship, ensure that you have selected "My partner & me" option at top of form and enter in their email and cell number

I am single, or I have entered my partner's full info

Billing & Payment

Fees for Services are Out-of-Pocket (info will be sent during scheduling)

If you have out-of-network mental health benefits & file a claim, your insurance provider will reimburse you a percentage of my fee, directly back to you. The percentage varies but is usually anywhere between 50-90%, after an out-of-network deductible is met.

Will use credit/debit card, HSA/FSA account, Venmo or Apple Cash to pay at time of service

Client Preferences

Preferred appointment times - ALL SESSIONS ARE TELEHEALTH VIDEO CALLS

PLEASE CHECK ALL THAT APPLY - Consults/Evals are 75-90 minutes long and scheduled in EASTERN STANDARD TIME

ASAP - I want first available, any day and time Mondays Tuesdays Wednesdays Thursdays Fridays Morning (9:00-11:00am EST) Lunchtime (12:00-1:00pm EST) Afternoon (2:00-5:30pm EST - latest start is 4pm)

Is there anything you'd like your practitioner to know?

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.