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Full Name *

Phone *

Address *

City *

Postal code *

Email *

Child's Name *

Child's Age *

I'm Seeking Services For *

I'm Seeking Services For

Whom Are You Seeking Counseling For

Whom Are You Seeking Counseling For?

Provide 3 Times You Are Available For First Appointment *

Briefly Describe The Issue You Would Like to Work On

Have you reviewed our Private Pay Policy? *

Yes

No

*If you have not reviewed our private pay policy, please do so before continuing by clicking on "Pricing" above.

Are you or your child currently enrolled in Medicaid? *

Yes

No

What Is Your Marital Status? *

Single

Married

Separated

Divorced

What Is the Best Way To Contact You? *

Phone

Email

Text Message

How Would You Like To Receive Services *

In-Person Only

Telehealth Only

Open to Both

How Did You Hear About Us? *

Email & Text Message Risk Acknowledgement and Use Consent *

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