Please fill out this form if you are requesting an appointment for your child or for someone else for whom you are a guardian. We will contact you soon with next steps to find a therapist. Thank you!

We are always grateful when clients find us! How did you hear about us?

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Parent/Guardian Email Address *

Parent/Guardian Phone Number *

Parent's Street Address *

Preferred Method of Contact *

Child/Dependent's First Name *

Child/Dependent's Last Name *

Child's Date of Birth *

Child's Gender Identity?

Child's Preferred Pronouns?

Will you be using EAP benefits? *

Will you be using insurance benefits? *

What Insurance Company do you have?

What is the name of the primary insured person for this plan?

What is the birthday for the primary insured person for this plan?

What is the member ID for this insurance plan?

If there is a secondary insurance plan, please provide the plan name, primary insured and birthday, as well as the member ID.

What type of services are you seeking for your child? *

Please select your primary reason for seeking therapy for your child: *

Select additional reasons for seeking therapy below (check all that apply): *

Which quality is most important to you in a therapist? *

Preferred Appt Time

Preferred Appointment Days

Are you looking for In Person, Telehealth, or a Combination?

Telehealth

In Person

Combination

No Preference

Are you open to Telehealth?

Yes

Maybe

Please describe in your own words your reason for seeking therapy for your child: *

Are you a Client Care Coordinator filling this out on behalf of a new client? *

To submit this form, please first ensure that all required* fields are complete. By submitting this form, I understand that I may receive text communication to the phone number provided. I can opt-out of this communication at any time by responding STOP.