Full Name
*
Child's Name
Phone
*
Email
*
Address
*
City
*
State
*
Postal code
*
Child's Age
*
Relationship to the Child
*
Your Relationship to the Child
Parent
Guardian
Other
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Whom are you seeking counseling for?
Whom Are You Seeking Counseling For?
Child
Parent/Guardian
Family
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Current parent or guardian relationship status
*
Married
Current or Past Separation
Going through the process of Divorce
Divorced
Never Married
Domestic Partnership
How would you like to receive services?
In-Person Only
Telehealth Only
Open to Both
Interested in joining an 8-week Circle of Security Parent Group?
Yes
No
Please Provide 3 Times Your Child Is Available for Counseling
*
Would your like first availability or to work with a specific clinician?
(select all that apply)
First Availability
Liz Blaha
Jonathan Caes
Elizabeth Doppler
Taylor Simerly
Carly Schrimpl - Telehealth Only
Cheryl Welsh
Susan Stutzman
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What's the Best Way to Contact You?
Phone
Email
Text Message
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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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