• Welcome to Mala Child & Family Institute

    We are glad you are here. This form helps our team guide you toward the right services, providers, and next steps. Whether you are new to Mala or already receiving care, this form helps us coordinate care thoughtfully and efficiently.
  • Emergency Disclaimer: If you or someone you know is experiencing a crisis or emergency, please call 911 or go to your nearest emergency room. Mala Child & Family Institute does not provide emergency services.

  • Relationship To Mala

  • Which of the following best describes you right now?*

  • Who Is Seeking Support

  • Please complete a separate form for each individual client seeking services so we can create the correct enrollment pathway and care plan.

  • Who is seeking support?*
  • Has anyone in your household previously received care at Mala?

  • Client Information

  • If the client is a teen and you would like them to receive appointment reminders directly, you may include the teen’s email address and phone number.

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Parent/Guardian Information

  • Because children do best when their support system is coordinated, we require a second adult contact for all child clients. Please provide the contact information for the other legal parent. This is required for divorced or separated households.

  • Format: (000) 000-0000.

  • If parents are divorced or separated, the second contact must be the other legal parent if they share legal custody.

    Mala does not manage payment arrangements between parents. Parents are responsible for managing payment agreements between themselves.

  • Format: (000) 000-0000.
  • Are the child's parents divorced or separated?*
  • Do both parents share legal custody?*
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  • Adult Emergency Contact

    We require an emergency contact for all adult clients to support safety and continuity of care.
  • Format: (000) 000-0000.
  • Services of Interest - Psychotherapy

    Services of Interest - Psychotherapy

    (e.g., play therapy, art therapy, relational counseling, individual therapy for youth or adults, parent coaching, executive function coaching)
  • Are you currently seeking psychotherapy/counseling services?*

  • Psychotherapy

  • Please note that our psychotherapy waitlist for BCN clients is 6+ months long. If you have BCN and would like care sooner, we encourage you to consider private pay at $185/session or higher, or working with a supervised trainee for $50/session when available.

  • ⏱ Reducing your wait: Our in-person appointment slots at 4:00 PM and later have the longest wait times. Being open to virtual sessions or appointments at 3:00 PM or earlier can significantly reduce your wait. 💡 Also worth knowing: Consistent parent coaching can be just as effective as individual child therapy for many concerns — and it can happen during the day, virtually, offering much more flexibility for families.
  • Which therapy services are you interested in?*
  • Main therapy concerns*
  • Services of Interest - Occupational Therapy

    Services of Interest - Occupational Therapy

    OT can help with sensory needs, emotional regulation, fine and gross motor skills, feeding, self-care, daily routines, and greater independence at home, school, and in the community.
  • Are you currently seeking occupational therapy?*

  • Occupational Therapy

  • ⚠️ Important — If you have BCN or Priority Health insurance, Mala requires an autism diagnosis from a medical provider in order to offer occupational therapy through insurance.

  • What OT-related concerns are present?*
  • Previous diagnoses*
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  • Service of Interest - Speech and Language Therapy

    Service of Interest - Speech and Language Therapy

    Speech therapy can help with communication, understanding and using language, social interaction, speech clarity, fluency, voice, and feeding or swallowing needs across daily life.
  • Are you currently seeking speech and language therapy?*

  • Speech and Language Therapy

  • What speech/language concerns are present?*
  • Previous diagnoses*
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  • Services of Interest - Psychological Evaluation

    Services of Interest - Psychological Evaluation

    Psychological evaluations can identify or clarify diagnoses such as autism, ADHD, anxiety, OCD, PTSD, learning disabilities, and personality disorders, while providing personalized recommendations for care and support.

  • ⚠️ Important — This service provides formal diagnostic testing for concerns such as autism, ADHD, anxiety, OCD, PTSD, learning disabilities, and personality disorders. An evaluation is not required to receive therapy, medication management, or other Mala services.

  • Are you currently seeking psychological evaluation/testing to rule in/out a formal mental health diagnosis?*

  • Psychological Evaluations

    What type of evaluation are you seeking?

  • ⚠️ Important — We do NOT offer evaluations for custody, disability/social security/job readiness, court/legal purposes, or neuropsychological testing related to dementia or memory decline.

  • Comprehensive Evaluation - All Ages
  • Adult Abbreviated Virtual Evaluation
  • Private Pay Learning Evaluation - All Ages
  • Has the client completed previous testing?*
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  • Services of Interest - Medication Management

    Services of Interest - Medication Management

    Medication management can help evaluate whether psychiatric medication may be beneficial, prescribe when appropriate, and monitor its effectiveness and side effects over time.
  • Are you currently seeking medication management/psychiatry?*

  • Medication Management/Psychiatry

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  • Service of Interest - Groups/Workshops

    Service of Interest - Groups/Workshops

    Group therapy offers support, connection, and practical skills alongside others with similar experiences, needs, or goals.
  • Are you currently seeking group therapy or workshops? We have many starting soon for all ages!!!*

  • Groups

  • Which groups/workshops are you interested in?
  • Would you like to be contacted about future groups/workshops?

  • Insurance & Payment

  • We verify your benefits before you begin care with us.

  • Insurance Company Name/Payment Option*
  • Primary Holder Date Of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • We will asked you to provide a copy of your driver's license later during enrollment and prior to the first appointment. We also require two active credit cards on file.

  • Scheduling Preferences

  • Preferred Location:*
  • Virtual or in-person preference*
  • Availability*
  • Would you be open to daytime, before-school, or virtual appointments if it meant starting sooner?*

  • Accessibility & Support Needs

  • Are there any other Mala services you would like to explore? Select all that apply.

  • CURRENT CLIENT ADDING SERVICE

    This form is also for former clients returning.
  • Who is requesting new service(s)?*
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Current/Past services at Mala*
  • Service(s) you want to add/start:*
  • Has insurance changed since last enrollment?*

  • Consent to Contact

    I consent to being contacted by Mala Child & Family Institute regarding services, scheduling, care coordination, and enrollment. I understand this does not establish a therapeutic relationship.
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