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Child Intake Form
Office appointments for children and teens 9-17.
Please only use form for scheduling an intake. Please email me directly if you have any questions.
Child's First Name
Child's Last Name
Birthday
*
required
Mother/Legal Guardian First & Last Name
Mother's email
Mother's Phone
Father/Legal Guardian First & Last Name
Father's email
Father's Phone
Insurance
Choose an option
Goals for treatment
Consent to the terms & conditions. Both parents will be contacted about completing consents prior to scheduling the first appointment.
Submit
Thanks! We will reach out to schedule your first appointment!
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