Parent/Guardian's Name

First Name

Last Name

Parent/Guardian Email Address

Parent/Guardian Phone Number

(###)

###

####

Teen's Name

First Name

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?

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.