ShineBright Mentoring Client Sign Up
For clients and / or parents to sign up for our independent living and life skills mentoring services
Client Name
*
First Name
Last Name
Client Phone Number (Cell Only)
Client (or parent) e-mail address
*
example@example.com
Parent Name (if Applicable and for Billing)
First Name
Last Name
Parent Phone Number (Cell Only)
Parent e-mail
example@example.com
City or Town Client Resides In
*
Please Include State
Mentor Location Meeting Preference
*
Willing to meet remotely
Only wishes to meet in person
Hybrid (Only possible in select areas)
Other
How did you hear about us? For example: "I found ShineBright via my doctor" or "I found you via Instagram" (If you were referred to us via a clinician please include his or her name)
*
Please enter email address you would like us to use to bill you (only used if you decide later to use our services). (If already entered above - please enter "Above" in field below).
What is your number one goal in life? If parent is filling this out - you do not necessarily have to answer this
What is your biggest challenge in life?
Is there anything else you would like to tell us about yourself (or your son or daughter)?
Submit Form
After Submitting Form Above - Please Schedule Your Free 15 Min. Phone Consultation with Ryan Casey (Typically this is only parent(s) and Ryan in this call)
Please Download Our Policies + FAQs, and Review
Lastly - Please Download Our Rates Here (Note: Private Pay is $175 per session - if you utilize Self-Determination or OPWDD it is $225 / session)
For more information visit -
Chippens.org
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