Family/Youth Therapy Application

1
How did you first come in contact with us?* This field is required.
Google
Facebook
Instagram
Referral
Other
2
Please state your referral* This field is required.
3
Which of the following best describes your current relationship status?* This field is required.Please tell us a little bit about yourself, so that we can better understand your situation.
Single
Dating / Long Term Relationship / Engaged
Married
Divorced
Other
4
The challenges you face at age 18 aren't the same as those you'll face at 68. To help us understand what you would most benefit from, which of the following best describes your age?* This field is required.
20's
30's
40's
50's
60's
70's or older
5
If you are reaching out for family therapy or gender affirming care for a child, adolescent, or young adult, which of the following best describes your child's age?* This field is required.
under 7
7-10
11-13
14-15
16-17
18-24
25 or older
6
If you're seeking services for a child, adolescent, or young adult, which of the following best describes your child's Iiving 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
7
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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Ok
8
Thank you! 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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Large
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Ok
9
And as we mentioned, openings are limited as there's only so much space available in our schedules. Why should we consider accepting your family/child for one of those spots?* This field is required.Tell us what makes your readiness for this work unique or apparent.
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Large
Normal
Small
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Ok
10
Depending on your needs, working with us usually requires an investment of at least $1,500-$3,000. 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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Ok
12
Not Finished Yet... Last (And Most Important) Step! Please confirm your contact information below and then schedule a time for a consultation with our office manager to get you started and connected with the right clinician.* This field is required.STEP 1: Submit your contact information below. STEP 2: On the next page, PICK OUT A TIME that works with your schedule. STEP 3: You'll receive an email immediately from Acuity with your scheduled time. We will be calling you on that date/time, so mark your calendar.
Please enter your name
Please enter your email
Please enter your phone
Please enter your zip code
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