Family/Youth Therapy Application

1
Tell us about your family/child and what's making you look for guidance at this time.* This field is required.Please be as detailed and specific as possible.
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2
Which of the following best describes your child's age?* This field is required.Select your child's age range.
under 7
7-10
11-13
14-15
16-17
18-24
25 or older
3
Which of the following best describes your child's living situation?* This field is required.
Lives at home
Lives with another parent
Splits time between households
Is away at college, still dependent
Lives on their own independently
Other
4
Please describe your child's living situation:* This field is required.
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5
The challenges you face at age 18 aren't the same as those you'll face at 68. To help us understand what may be most beneficial to you, which of the following best describes your age?* This field is required.Select your (parent) age range.
20's
30's
40's
50's
60's
70's+
6
Which of the following best describes your current relationship status?* This field is required.Please tell us a little bit about yourself (parent), so that we can better understand your situation.
Single
Dating / Long Term Relationship / Engaged
Married
Divorced
Other
7
Describe your relationship status:* This field is required.
8
Since we only have a limited number of openings available to work with new families, please tell us what you are looking to achieve as we work together.* This field is required.Please be as detailed and specific as possible. What’s your vision or dream here? How would you define “success”?
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9
As a specialized practice, our openings are limited and we want to make sure that we are a good fit for what you are looking for. Could you say more about why you feel ready for this work now? (Please share why you are confident in your ability to commit in this specialized work at this time)* This field is required.Tell us what makes your readiness for this work unique or apparent.
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10
Depending on your needs, working with us usually requires an investment of at least $2500. Have you made the funds available to make this investment right now?* This field is required.
Yes
No
11
Given the investment described above, how are you hoping to cover the cost of working with us?
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12
How were you referred to us?* This field is required.
Google
Facebook
Instagram
Referral
Other
13
Please specify your referral* This field is required.
14
Not finished yet...the last (and most important) step: please confirm your contact information below and schedule a call with our office to get you connected with the right clinician.* This field is required. *Note: This is an administrative phone consultation, minor clients are not expected to join. STEP 1: Submit your contact information below. STEP 2: On the next page, pick a time that works with your schedule STEP 3: Receive a confirmation email from Acuity with your scheduled time. We will be calling you on that date/time, so mark your calendar.
Please enter your first and last name
Please enter your email address
Please enter your phone
Please enter your 5-digit zip code
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