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Full Name
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Phone
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Address
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City
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Postal code
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Email
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Child's Name
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Child's Age
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I'm Seeking Services For
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I'm Seeking Services For
Anxiety
Depression
ADHD
OCD
Substance Abuse
Other
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Whom Are You Seeking Counseling For
Whom Are You Seeking Counseling For?
Child
Parent/Guardian
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Provide 3 Times You Are Available For First Appointment
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Briefly Describe The Issue You Would Like to Work On
What Is the Best Way To Contact You?
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Phone
Email
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How Would You Like To Receive Services
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In-Person Only
Telehealth Only
Open to Both
How Did You Hear About Us?
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Email & Text Message Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Pivot Child Psychological Services practitioners and/or office staff communicating with me via email or text message
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