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Mala Child and Family Institute Intake Form
Mala Child and Family Institute Intake Form
Thanks for being here! Please fill out this form to be added to our intake list. Do not use this form in case of emergency or if you or your child are feeling suicidal. Instead, please call 911, go to your nearest emergency room, or contact the national suicide hotline at 800-273-TALK (8255).
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  • 1

    Did you know that parent coaching is equally as effective at treating many childhood conditions? And the best part is that these services are covered by insurance! Consider enrolling in parent coaching sessions. It can be as easy as a virtual appointment during your lunch break, or taking a break to come in person.

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  • 2

    Important note: If you are certain that what is best needed for your child's direct individual therapy, we strongly urge you to consider a daytime slot rather than waiting on the waitlist for an after school slot. We can provide a note for the school, and work closely with the teachers to best support your child's mental health AND academic needs. And, the good new is that being pulled out of school to receive mental health care will actually improve your child's academic performance! So it's a win win!

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  • 3
    You can request this appointment for yourself, on behalf of someone else, or for both you and your partner. Please choose below.
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  • 9
    We are only in network with Blue Cross Blue Shield. We provide out of pocket services to clients who have other insurance plans. Please look at our out of pocket costs on our website. We will provide private pay clients a superbill so they can seek reimbursement from their insurance.
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  • 10
    This is the date of birth of the person you are seeking care for.
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    Pick a Date
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  • 15
    You will see each clinician's current availability in parentheses.
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  • 16
    Wait time can range from a few weeks to several months. If you choose one of these clinicians, we will still reach out if we find another match for you and offer you the alternative clinician.
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  • 18
    Please indicate all possibilities. The wait time is longer for evening hours.
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  • 19
    Please also note here if you have a strong preference for a specific counselor and would like to be considered only for their waitlist. This could effect wait time.
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