Minor Contact Information
Please complete the following information. Our Clinical Coordinator will review your information and respond as soon as possible. 

PLEASE check your SPAM/Junk folders for email responses if you have not heard from us within three business days. 
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Email *
Name of Person Completing the Form *
Name of Minor Requesting Services *
Date of Birth of Minor *
MM
/
DD
/
YYYY
Age of Minor *
Preferred Pronouns *
Required
School Currently Attending *
Current Grade Level *
Type of Service Requesting *
Required
Reasons for Seeking Counseling (Please be specific as to your child's current needs to better help us know which therapist would be the ideal fit.) *
Referral Source *
Any Additional Information
Name of Parent #1 *
Email *
Phone Number *
Name of Parent #2 *
Email *
Phone Number *
I understand Summit Emotional Health is an out of network mental health provider and does not accept insurance. I reviewed the payment policies at www.summit-eh.com/payment. *
Required
I understand that due to the high demand for mental health services, my child's appointment will likely be offered during the school day hours. *
Required
I understand that parental consent from both parents are required when treating minors if joint legal custody is shared, regardless of marital status.  *
Required
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