Initial Contact Form

1

Name

First Name

Last Name

2

EmailSometimes our emails go to spam, but this is often our first mode of contact. Please keep an eye out for emails.

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Is it ok to leave a message on this number?

Yes

No

5

Are you wanting therapy for:

Individual

Minor

Couple

Family

6

How old is the minor that you are requesting therapy for?

7

Is it okay to text this number with information on therapists and links to schedule?

Yes

No

9

Please describe any relevant custody, divorce, or parental responsibility orders in place.

10

Please share a little about why you are seeking therapy at this time:

11

Do you have insurance? Which?

12

What is your Medicaid Number?

13

Do you want services:

In-person

Online

Either

14

Do you have any scheduling requirements that are important to know?

16

Anything else important that you would like to add?