The Wise Family Wellness

Please fill out this form if you are requesting an appointment. We will contact you soon with next steps to find a therapist. Thank you!

Full Name *

Client Name: *

Email *

Phone *

Address *

City *

State *

Postal code *

Client Date of birth *

Clients Sex *

Clients Gender Identity

Relationship to the Client *

Please select the service(s) that you are looking for/interested in: *

Individual counseling for my child

Individual counseling for myself

Family counseling

Parent coaching/counseling

Group therapy

Testing & Assessment

If you are seeking Testing & Assessment services, please select your area of interest:

What brings you in today? *

If you are inquiring for your child, is there any custody paperwork we need to be aware of? Please note it is our practice policy (and a Virginia law) that both parents, when they share legal custody, sign off on therapy. *

Location Preference *

In person (Alexandria office)

In person (Falls Church office)

Telehealth

Preferred Appointment Time:

Would you like first availability or is there a specific clinician you are interested in working with?

We are an out of network practice, are you planning on submitting to your insurance for potential reimbursement? *

What's the best way to contact you? *

How did you hear about us? *

Would you like to be added to Wise Family Wellness's email list? *

STOP! Have you reviewed our Fees & Insurance page? Please note our intake session across the board is 60 to 75 minutes long and priced at $300, due at time of booking. Regular sessions will drop down to 50-60 minute sessions and are priced based on the clinicians rates shown on our website. https://www.thewisefamily.com/getting-started/fees-insurance/

I consent to Wise Family Wellness therapists and/or administrative staff communicating with me via email and/or phone.