Teen/Caregiver Appointment Request Form

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Parent/Guardian Email Address *

Parent/Guardian Phone Number *

Teen's First Name *

Teen's Last Name *

Teen's Phone Number *

We will not contact your teen, however, our system requires this information for scheduling an appointment.

What is Your Teen's Age? *

Teen's Date of Birth *

What is Your Teen's Gender Identity?

What Pronouns Does Your Teen Use?

What Is Your Primary Reason For Seeking Support? *

Describe In Your Own Words Your Reason For Seeking Therapy. *

What Is Your Preferred Location *

What Is Your Preferred Billing Tier *

How Did You Hear About Us? *

Schedule Your Free Client Match Consultation Call After You Hit Submit.