Therapist's Consultation Request Form

Name of the form

In order to start the process, we will need you to connect with the therapist you are hoping to schedule with first to see if he or she has availability for you, can meet your clinical needs, and has a schedule that may fit yours.

Let's begin by selecting which therapist you would like to work with*

Since you selected Dr. Accurso, you understand that these clinicians are only providing ADHD psychoeducation/support, school liaison work, or v or virtual therapy. In addition, they are working as extenders of Dr. Dale Richards and under his direct supervision

Name of the potential Client*

First NameLast Name

What name would you like to be called by? (If different from the above)

Age of the client*

Gender of the client*

MaleFemaleOther

Preferred pronouns

What other pronoun(s) do you/they prefer?

Email address of the adolescent client

example@example.com

Phone Number of the adolescent client

Please enter a valid phone number.

Address of client*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of contact person (if different from above)

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Insurance*

Other Insurance

Please briefly describe the reason you are seeking counseling

Jenilee's Email

example@example.com

Colleen's Email

example@example.com

Sara's Email

example@example.com

Megan's Email

example@example.com

Paula's Email

example@example.com

Marjan's Email

example@example.com

Kelli's Email

example@example.com

Jessica's Email

example@example.com

Bria's Email

example@example.com

Todd's Email

example@example.com

Alex's Email

example@example.com

Jordan's Email

example@example.com

Heather's Email

example@example.com

Carrie's Email

example@example.com

Jenni's Email

example@example.com

Danielle's Email

example@example.com

Cecilia's Email

example@example.com

Mirranda's Email

example@example.com

Megan P's Email

example@example.com

Keeli's Email

example@example.com

*Therapist's Email

example@example.com

Denise's Email

example@example.com