New Client Interest Form

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 therapy services are you interested in?*

Child/Teen CounselingParent CoachingFamily CounselingGroup Therapy(Reduced Rate)Graduate-Level Intern Student Sessions
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).*

Early morning (8am-11am) (less wait time)Early afternoon (11am-2pm) (less wait time)After school/evening appointments (3pm- 5pm) (most desired time)Evening appointments (5pm or later) (most desired time)First available
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:*

Together or never marriedJoint decision-making (we will need both parents' consent for treatment)Sole custody (person completing form)Other
All services are currently private-pay. Individual fees range from $80 to $125. Graduate Student Intern-level therapist rates are $80. Group rates are $60 for 1.5 hours. 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.*

I understand and agree to paying out of pocket for services
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.*

I understand
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