Name *

Please note that all this information will be sent to a secure line. Filling out this form entirely will allow for faster service. All your information will be kept safe and confidential.

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

Please put you or your child's DOB

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How can we help you grow? *

Interested in:

Child Psychological Evaluation for ADHD, Autism, Trauma, or Learning Disabilities

Adult Psychological Evaluation for ADHD, Autism, Trauma, or Learning Disabilities

Individual Therapy (Adult 18+)

Individual Therapy (Child under 17)

Couples Therapy

Parent Training/Support

Availability *

Please select days that you are available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Times *

Best Times for Therapy

Morning/Early PM (11-1PM)

Afternoon (2PM-4PM)

Evening (5PM-8PM)

Session Preference (Remote or In-Person): *

As of December 2024, there is currently a wait-list for all in person sessions after 3pm. We have limited availability for in-person therapy during the day. We have immediate openings for virtual sessions.

In person only

Virtual only

I am flexible

How did you hear about us? *

Please select

Referral from a therapist/psychiatrist

Referral from family/friend

Referral from my child's school

Referral from hospital

Social Media: IG/Tiktok/Facebook

Google Search

Psychology Today

My Insurance Company

Other