Confidential Therapy Request Form

Full Name

Email *

Phone *

Date of birth

Gender

Male

Female

Which Service(s) are you interested in?

Individual Therapy

Group Therapy

Developmental Evaluation (ages 3-5)

School Age Evaluation-Dyslexia Only

School Age Evaluation-ADHD Only

School Age Evaluation-COMPREHENSIVE

Adult Evaluation

What type of visit works best for you?

In person

Telehealth

What is the main area you’d like to work on?

Managing Stress

Improving Relationships

Overcoming Anxiety

Coping With Depression

Building self-confidence

Other

What challenges have been most difficult for your recently?

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