Minor Appointment Request Form
Let us know how we can help you! If you are a parent completing this form on behalf of your child, please answer these questions from their perspective.
What state are you currently located in?
*
California
Florida
Idaho
Kansas
Nevada
Tennessee
Texas
Other
What are you struggling with?
*
Anxiety, fear or worry
Sadness or Depression
Stress
Family or Friend Relationships
Alcohol or drug use
Dealing with something difficult from the past (Trauma)
Bullying or social issues
School or academic problems
Other
What type of therapy are you looking for?
*
Individual
EMDR Therapy
Family Therapy
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Next
Minor's Name
Please complete the following information for the minor, leave phone number or email address blank if it is unknown or unavailable.
Minor's Legal Name
*
First Name
Last Name
Minor's Phone Number
Please enter a valid phone number. If the minor does not have a phone number, leave it blank.
Minor's Email Address
If the minor does not have an email address, please leave It blank.
What is your gender?
Please Select
Male
Female
What is your age range?
Please Select
5-9
10-12
13-18
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Next
Parent or Guardian's Information
Parent or Guardians Name
*
First Name
Last Name
Relationship to Child
*
Mother
Father
Stepparent
Legal Guardian
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Does this parent/guardian have legal custody to provide consent for counseling?
Yes
No
Contact Info for Second Parent or Guardian
Use this section for a second parent/guardian if applicable.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Child
Mother
Father
Stepparent
Legal Guardian
Other
Does this parent/guardian have legal custody to provide consent for counseling?
Yes
No
Are there any court orders, parenting plans, or legal agreements regarding custody, visitation, or decision-making for your child?
Yes
No
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Next
Almost Done!
A few more important questions to help match you to the best therapist...
Where are you looking to attend sessions?
In Person: Vacaville, CA
In Person: Roseville, CA
In Person: Knoxville, TN (Coming Soon)
Online
Availability
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times
*
Mornings (8 AM - 12 PM)
Afternoons (12 PM - 4 PM)
Evenings (5 PM- 8 PM)
How did you hear about Freedom Counseling Group?
Internet Search/Google
Recommended by a friend or family member
Recommended by a doctor
Other
Is there anything else we forgot to ask or would be helpful to know regarding you and your situation?
Let us know if there is any other information that would be helpful for us to be aware of as we match you to a therapist. We will do our best to get you scheduled for a free phone consultation
Please verify that you are human
*
Submit
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