Spectra Therapies Initial Contact Form

If this is an emergency, call 911 or go to the closest emergency department.

Please complete this form if you would like more information about our services or are interested in scheduling an appointment.  We will contact you by phone within two business days. Our office is closed on Fridays.

Information about our services and fees can be found on our website.

Spectra Therapies is out-of-network and does not accept any insurance.

Signing into google is not required.
Sign in to Google to save your progress. Learn more
Client Name *
First + Last Name
Age *
Gender *
Parent or Other Contact Name (If Applicable)
Relation to Client (If Applicable)
parent, therapist, guardian, etc
Phone #
 *
enter 10 digit number without symbols
Name of School or Occupation
Email
 *
Referral Source
 *
Website / Provider / Agency / Another client / Other
Which services are you interested in?
 *
Required
Reason for seeking services + previous diagnosis (If Applicable)
 *
Additional Comments
Such as: preferred provider, type of evaluation, which  group etc.
Is interest in our services in relation to any court-related issues?
 *
If parents are separating or divorced, are both parents in agreement to access our services?
 *
Out-of-Network
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This form was created inside of Spectra Therapies.