Appointment Requests Name * First Name Last Name Email * Phone (###) ### #### Date * MM DD YYYY Message By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Kristin Koliha LISCW harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. yes, i want to submit this Thank you for submitting your appointment request you should hear back from me shortly.