Request for SErvice
Please complete on behalf of the client
Client's Name
*
First Name
Last Name
Client Age
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Gender
Please Select
Male
Female
Nonbinary
Choose not to state
Your Full Name
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First Name
Last Name
Address
Street Address
City
State
Zip Code
Your contact
*
Phone Number
Email
May we leave you a message?
Yes
No
Please tell us who referred you?
Client's Current Symptoms or Concerns
Depressed mood
Racing thoughts
Excessive worry, reassurance seeking
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increased risky behavior
Avoidance
School Avoidance/Refusal
Rage
Hallucinations
Concentration/forgetfulness
Decreased need for sleep
Suspiciousness
Changes in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells and emotional lability
Obsessive Compulsive Disorder
BFRB (hair pulling/skin picking)
Hoarding
Panic
PANS/PANDAS
Other
I am an Out of Network Provider. Please Select Payment Type
*
Superbill for potential insurance coverage
Private Pay - out of network
What kind of support are you looking for?
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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