Virtual Clinic Intake Form
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Please read and agree to the terms and conditions below *
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Child's First Name *
Child's Last Name *
Date of Birth *
Parent/Guardian Name *
Street Address
City, State, Zip
Preferred Phone #
Email Address
What services are you interested in for your child?
Does your child currently receive therapy services or have they in the past?
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Enter the name of your child's current therapist, if known.
Has your child completed a therapy evaluation within the last year?
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Please email a copy of your child's evaluation to
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If you are unable to provide a current evaluation for your child, a new one will need to be performed by our therapist. The charge for a new evaluation is $150.00.
Why are you seeking therapy for your child?
Please tell us any specific concerns you have.
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