Child Counseling Contact Form
(PLEASE CHECK ALL THAT APPLY TO YOUR CURRENT SITUATION)
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Parent/Caregiver Name: *
Contact Number: *
Contact Email: *
Child's Name: *
Is Your Child Experiencing Any of the Following:  (Please Answer All Areas of Concern) *
Yes
No
Academic Underachievement
Adoption
Anger Control Problems
Anxiety
Attachment Disorder
Attention-Deficit/Hyperactivity (ADHD)
Autism Spectrum Disorder
Blended Family
Bullying/Intimidation Perpetrator
Conduct Disorder/Delinquency
Depression
Disruptive/Attention-Seeking
Divorce Reaction
Enuresis/Encopresis
Fire Setting
Gender Identity Disorder
Grief/Loss Unresolved
Intellectual Development Disorder
Low Self-Esteem
Lying/Manipulative
Medical Condition
Obsessive-Compulsive Disorder (OCD)
Oppositional Defiant
Overweight/Obesity
Parenting
Peer/Sibling Conflict
Physical/Emotional Abuse Victim
Posttraumatic Stress Disorder (PTSD)
School Refusal
Separation Anxiety
Sexual Abuse Victim
Sleep Disturbance
Social Anxiety
Specific Phobia
Speech/Language Disorders
What Health Plan Does Your Child Participate In? *
If Other or Multiple Health Plans, Please List Below:
What is Your Preferred Availability?                                    (PLEASE LIST DAYS & TIMES) *
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