New Client Interest Form

Name

First NameLast Name

Child's Name

Child's Age

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

How did you hear about us?

What location are you interested in?

Which therapist are you interested in seeing?

What is your availability to attend weekly appointments? (Less wait time for appointments during school hours, and we can provide your child with a school excuse) If your preferred clinician is not available at the requested time, we will do our best to pair you with a therapist that is).

Please briefly describe reasons for seeking therapy services at this time

Please be aware that we do not have the capacity to help with reunification therapy or high conflict custody battles that require court representation. If you are divorced and in a joint decision custody agreement, we must have the consent of both legal guardians in order to proceed with therapy.

Parenting arrangement:

Other

All services are currently private-pay or commercial insurance only. Individual fees range from $100 to $133. Graduate Student Intern-level therapist rates are $80. We can provide you with receipts to give to your insurance company to utilize out-of-network benefits (if applicable) as a courtesy, however payment in full is due at the time of service. Please note: We do NOT accept TennCare

After clicking submit, we will be in touch when we have a therapist available. If you have not received a call or email (check your spam!) you can give us a call at 423-328-1289. We appreciate your patience and understanding.