Contact Information Form

To contact the clinic, please complete the contact information form. A representative will get back to you within two business days.

Cancellation Policy: Appointment times are reserved just for you. Our waitlist can be long, and a late cancellation or missed appointment leaves a gap in your therapist’s day that could have been filled by another client. As such, we require 48 hours notice for any cancellations or changes to your appointment. Clients who provide less than 48 hours notice, or miss their appointment, will be charged the full session fee. Repeated cancellations may result in withdrawal of service and a return to the waitlist until attending regular therapy is possible.
Parent(s)/Guardians Names*
Child's First Name*
Child's Last Name*
Child's Birth Date*
MM slash DD slash YYYY
Child's Age
Child's Sex
Primary language(s) spoken by the family
Child's School
Child's Grade
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Enter Email Confirm Email
Referred By
Your First Name*
Your Last Name*
Family Home Phone*
Availability
Concerns/Questions*
Please indicate the reason for connecting with us today
Location*
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