Service Inquiry Form - Riya Vettickal, LPC

Please fill out the confidential form below. Riya Vettickal 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 832 463-2502.

Client First Name

Client Last Name

Please indicate your interest with Riya Vettickal, LPC.

Cell Phone Number

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

* Required

How did you find out about Riya Vettickal, LPC?

* Required

If other selected, please specify.

Please share anything else you want Riya Vettickal to know:

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

(Optional) Insurance Details

Subscriber Name

Subscriber Date of Birth

Relationship to Subscriber

Name of insured

Insurance company

Policy number

Group number

Claims address

Customer service or benefit phone number

Please leave this checkbox blank