Teen/Caregiver Appointment Request Form — Space Between Counseling Services

We are now working with KIDS, TEENS & YOUNG ADULTS. Click to learn more about our LGPC therapist Rae Buchanan

We are now also offering Dialectical Behavior Therapy (DBT). Click to learn more about DBT and schedule your next session

We are now ACCEPTING new clients and offering complementary therapist-matching consultation call to find your best match for therapy.

All our therapists are licensed in MD. Meet our therapists that are licensed to practice outside of MD.

Susan Stork, CST, will not be accepting NEW individuals + couples until Spring of 2025.

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian Email Address

Parent/Guardian Phone Number

(###)

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Teen's Name

First Name

Last Name

Teen's Phone Number

(###)

###

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

What is Your Teen's Age?

Enter Your Teen's Date of Birth

YYYY

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

What Days Are You Available?

What Times Work For You?

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