Request for Counseling Appointment

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Counseling services for children - Infants to 12 years old

Email *

Your Name:

Phone:

Child's first & Last name:

Child's Date of Birth:

Preferred day and time of appointment:

Name of Insurance company? Ground Work is an In-Network provider for BC/BS and Aetna. Ground Work is also a registered provider for the ESA (Empowerment Scholarship).

BC/BS

Aetna

Will submit payment receipts to ESA for reimbursement

Appling for sliding scale fee

Who referred you to Ground Work?

Anything you would like us to know?

By submitting this form you acknowledge and accept the risk of communicating your information via this unencrypted electronic system and continue despite those risks. By submitting you agree to hold Ground Work harmless for unauthorized use, disclosure, or access of your information sent via this electronic means.

A copy of your responses will be emailed to the address you provided.

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