Contact me

Name of prospective client*
First Last
Age of prospective client*
Date
Phone*
Email*
Address
City ZIP / Postal Code
Areas of Concern:
- Eating, body image or weight
- Anxiety
- Addiction
- Psychological Assessment for bariatric surgery
- Other (please explain in message)
Insurance
- Out of Network Insurance
- Medicare
- Self-pay (no insurance)
(Dr. Gill IS NOT in network with any commercial insurance plan)
What days and times of day, do you prefer for sessions? Check all the apply
- Sundays
- Evenings
- Daytime on Weekdays
Message*
If we have discussed time and date for initial appointment, please confirm below.
If parent is involved in setting up appointment or insurance
Parent Name
First
Email
Cell

(973) 820-5174

124 E. Mt. Pleasant Avenue Livingston, NJ 07039

Hours

I work 5 days a week including 2 evenings and 1 weekend day.