Appointment Request- Children/Teens Therapy

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Client Name *

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Parent/Guardian's Name *

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Last

Parent/Guardian Email *

Parent/Guardian phone # *

Office Location *Leominster, MAIndianapolis, INKissimmee, Fl

Services Needed *

• Individual Therapy
• Family Counseling
• Group Therapy
• Medication Management

Session Type *In PersonTelehealthBoth – Hybrid

Insurance Provider

Policy Number

Policy Holder's Name

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Why are you seeking therapy? *

• I am depressed
• I feel anxious/overwelmed
• I’ve been diagnosed with a mental disorder
• I’m struggling with relationships
• I experienced trauma
• I am grieving
• I want to improve self confidence
• I am battling addiction
• Recommended (by doctor, family or friends)
• Other

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