Full Name
*
Child's Name
Phone
*
Email
*
Address
*
City
*
State
*
Postal code
*
Child's Age
*
Relationship to the Child
*
Your Relationship to the Child
Whom are you seeking counseling for?
Whom Are You Seeking Counseling For?
Current parent or guardian relationship status
*
Married
Current or Past Separation
Going through the process of Divorce
Divorced
Never Married
Domestic Partnership
Deceased
How would you like to receive services?
In-Person Only
Telehealth Only
Open to Both
Please Provide 3 Times Your Child Is Available for Counseling
*
Would you like first availability or to work with a specific clinician?
(select all that apply)
What's the Best Way to Contact You?
Have You Read Our Private Pay Policy?
*
Yes
No
Would you like to receive our best parenting advice sent to your email?
Yes
No
How did you hear about us?
*
Briefly describe the issue you would like to work on.
Email Risk Acknowledgement and User 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 Kid Matters therapists and/or office staff communicating with me via email or text message
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