Information Request Form - PRESTIGE Evaluation and Consulting Services, LLC

PRESTIGE Evaluation and Consulting Services, LLC

Information/Scheduling Request Form

Please complete and submit the requested information below, including a brief description of the services you are seeking, and we will contact you as soon as possible. Please note that this form is not designed for use in a mental health emergency or crisis situation. If immediate attention is required, please go to the nearest emergency room or dial 911.

Contact via telephone or email and use of this website does not constitute establishment of a professional or therapeutic relationship with Dr. Daralyn Plains or Prestige Evaluation and Consultation Services, LLC. Only when you and Dr. Daralyn Plains of Prestige Evaluation and Consultation Services, LLC have both agreed to proceed with a specific service and have both signed an Informed Consent for Treatment, is a therapeutic relationship established.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Comment *

Submit

Prestige ECS