Prospective Client Name *

First Name

Last Name

Parent/ Caregiver Name (if applicable)

First Name

Last Name

Phone

(###)

###

####

What Services Are You Interested In? *

Therapy

Evaluation

Parenting Anxious Teens Group (Ages 12-18/ Middle/ High School)

Parenting Anxious Kids Group (Ages 5-11/ Elementary)

Thriving Tweens Group (6th-8th Grade)

Medication Management/ Consultation

Unsure/ 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”.

Note that filling out the inquiry form does NOT place you on a traditional waitlist or guarantee that you will receive services now or in the future. Rather, it is a way for you to express interest so that our providers will see your inquiry when they have an opening. Please visit the pages under our “More Info” tab on our website for additional information about our Wait Times & Scheduling Process, Insurance & Fees, and more.