Please Fill Out The Information To Get Support As Soon As Possible. Thank you!

Full Name *

Phone *

Address *

City *

Postal code *

Email *

I'm Seeking Services For *

Provide 3 Times You Are Available For First Appointment *

Briefly Describe The Issue You Would Like to Work On

What Is the Best Way To Contact You? *

Phone

Text Message

How Would You Like To Receive Services *

In-Person Only

Telehealth Only

Open to Both

How Did You Hear About Us? *

Email & Text Message Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Pivot Child Psychological Services practitioners and/or office staff communicating with me via email or text message