Parent/Guardian Name: *

First Name

Last Name

Phone Number *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Gender *

Male

Female

Does your child currently receive therapy? *

Yes

No

Does your child have a diagnosis or evaluation recommending therapy? *

Yes

No

Would you be open to trying one of our network therapists if they have availability and are a good match? *

Yes

No

Therapist's Name (If applicable)

First Name

Last Name

Therapist’s phone number

(###)

###

####

Will you need us to pay the full amount or just a copay? *

Full Amount

Copay

Do you currently have insurance? *

Yes

No

Does your insurance cover therapy sessions? *

Fully

Partially

Not at all

Are you currently receiving any form of public assistance? *

Select all that apply.

SNAP (Food Stamps)

Medicaid

SSI or SSDI

WIC

Housing Assistance (Section 8, etc.)

Unemployment Benefits

None

Other

Do you or your spouse currently work? *

Yes, full time

Yes, part time

No

Other

What is your current employment status? *

Employed

Self-employed

Unemployed

Homemaker

Student

Disabled

Retired

Other

What is the main source of your household income? *

Employment

Government Assistance

Family Support

Child Support/Alimony

Other

Do you have any outstanding debts or loans that affect your financial situation? *

Yes

No

Have you applied for financial help from other organizations or programs? *

Yes

No

Were you referred to us by someone? *

No

Yes

No‑Show Acknowledgment *

By submitting this form, I acknowledge that I am responsible for any session fees for appointments missed without 24‑hour advance notice.

I understand and accept this policy.

Eligibility & Funding Policy Acknowledgment *

By submitting this form, I confirm that I have fully read and understood the Eligibility & Funding Policy linked in the website footer.

I understand and accept this policy