Amy- Inquiry Form

Confidential Inquiry Form
Amy Fuller, PhD, LMFT-S, LPC-S

Please fill out the confidential form below. Dr. Fuller's Office Manager will contact you on the next business day to answer any questions you may have and potentially set up your first visit.
If you want to connect more quickly please call 832-848-0870.

First Name

Last Name

Please indicate your interest with Dr. Fuller

Cell Phone Number

Would you like to receive relational and mental health resources from Fuller LIfe?

* Required

How did you find out about Dr. Fuller?

* Required

If other selected, please specify.

Please share anything else you want Dr. Fuller to know:

Would you like to find out if your insurance would cover the cost of therapy?

(Optional) Insurance Details

Dr Fuller is out of network with all insurance panels, but as a courtesy, we can verify benefits and submit the out of network claim.

Subscriber Name

Subscriber Date of Birth

Relationship to Subscriber

Name of insured

Insurance company

Policy number

Group number

Please leave this checkbox blank