Appointment Request – Children/Teens Please enable JavaScript in your browser to complete this form.Client Name *FirstLastIs client under 18 years old? *YesNoRelationship to Client *Parent/GuardianSelfParent/Guardian Name *FirstLastEmail * Phone *Session Type *In PersonIn Person – GroupTelehealthBoth – HybridPayment Method *Self PayInsuranceInsurance ProviderWhy Are You Seeking Therapy? *I Am Anxious/OverwhelmedI am DepressedStruggling with relationshipsI Am GrievingBattling AddictionI Want To Improve Self ConfidenceI Experienced A TraumaRecommended (Family, Friends, Doctor)I Have A Mental DisorderOtherWould you like to opt in to text message? *YesNoBy opting in, you consent to receive text messages regarding appointment scheduling, including reminders, cancellations, and updates. These messages may also include information related to copays, insurance, and other billing matters.Submit
