Your email for communication about therapy

Preferred form of communication if different than above

Your city and state

Name and age of your child/children:

We work exclusively with parents and caregivers of children ages 1-12. For other ages please contact your insurance company to request a list of therapists who can work with your child's age group.

What are your child's anxious or disruptive behaviors and what are your concerns for your child/children?

Does your child/children hit and if so, how often?

Has your child/children every received therapy, and if so, how did it work out for your family?

Does your child/children have any major medical issues or history of hospitalizations?

Name of second parent/caregiver if any:

Email for second parent/caregiver if any

Please provide name of person above who referred you.

Contact Information