Prospective Clients

Prospective Clients

Please fill out this form to tell us a little about you and your goals so we can ensure our practice aligns with the support you need. Responses do not auto save, please plan on completing in one session.
If you are currently experiencing immediate safety concerns, thoughts of self harm or a mental health emergency please call or text 988, call 911 or proceed to your local emergency room.

This form is for non-emergency inquiries and is not monitored for real-time response.
Who is completing this form?
Full name of person completing this form

First NameLast Name
If you go by a different name, please enter it here
Name of the person completing the form
Pronouns of person completing form
Email address of the person completing this form
example@example.com
Phone number of the person completing this form
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth of person completing this form

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Little House operates as an out-of-network provider, and payment is due at the time of your visit. To help you get reimbursed, we happily provide courtesy billing for superbills to your insurance company. You can find all the details about our rates and insurance on our website HERE.

Full name of prospective client

First NameLast Name
If they go by a different name, please enter it here
Name of the prospective client
Pronouns of prospective client
Your relationship to the prospective client
Prospective client's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of school