Prospective Client Name *

First Name

Last Name

Parent/Caregiver Name *

First Name

Last Name

Phone

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Specific Concerns *

Please select from the options below.

Anxiety

Depression

Adjustment to chronic health condition

Pain management

Picky eating/ARFID

Encopresis

Tic disorders

Parent Consultation/Training

Challenging behaviors in my young child

Other

Please review the disclaimer below and press SUBMIT *

I acknowledge that electronic communication, including web forms and email, is limited in terms of privacy and may be intercepted by a third party. I also acknowledge that this electronic communication does not constitute a therapeutic relationship.

Please note that you will NOT receive an email copy of the form. This is because there is not currently a way to send a copy of the form to you in a HIPAA-compliant way. If you would like to keep a copy for your own records, please screen-shot the form before you hit “submit”.