GHE Application

1
Please state your referral* This field is required.(Please be specific: include provider and facility name, reason for referral)
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2
Are you seeking services for yourself or for your child?* This field is required.
Myself
My child
3
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.
18-24
25-29
30's
40's
50+
4
Which of the following best describes your child's age?* This field is required.
10 or under
11-13
14-15
16-17
5
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
6
Please describe your relationship status:* This field is required.
7
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
Not applicable
Other
8
Since we only have a limited number of openings available to work with new clients for a Gender Health Evaluation, please tell us about yourself and is making you seek these services at this time. * This field is required.What you are looking to achieve as we work together?
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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.Please be as detailed and specific as possible.
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10
A thorough biopsychosocial evaluation is required for minors and young adults. Depending on your specific needs, this process requires an investment of at least $1,350. Have you made the funds available to make this investment right now?* This field is required.
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11
Depending on your specific needs, this process requires an investment of at least $650. Have you made the funds available to make this investment right now?* This field is required.
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12
Given the investment described above, how are you hoping to cover the cost of working with us?* This field is required.
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13
Not finished yet...the last (and most important) step: please confirm your contact information below and schedule a call with our intake manager.* 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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