Schedule a Consultation with The Center for Family Unity

Part 1: Parent/Guardian Information

First Name *

Last Name *

Phone

Email *

Part 2: Child's Information

Child's First Name *

Child's Age *

Relationship to Child *

Part 3: Therapy Needs

What are your main concerns? *

Has your child received therapy before? *

Yes

Preferred Appointment Type *

In Person

Online

Either

Part 4: Consent and Agreement

Consent: *

I understand this form is for appointment requests only and does not constitute a therapist-client relationship until confirmed.

By checking this box, I consent to receive transactional text messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications. Messages will not contain personal health information. Standard message and data rates may apply. Message frequency may vary. Text HELP for help or STOP to opt-out. Please note that text messaging may not be a fully secure form of communication.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.