My Child's Information
You can submit this form by clicking the button at the bottom.
Your information will be sent to Charles Glazier, LICSW, at The Way To Better, Inc.
25 Main Street, Wayland MA 01778
charles@thewaytobetter.com
617-645-5048
Questions marked with a red asterisk are required information.
* Required
My preferred prefix is:
Mr.
Ms.
Dr.
My first name is:
*
Your answer
My last name is:
*
Your answer
My preferred nickname is:
Your answer
My birthdate is:
*
Your answer
My home street address is:
*
Your answer
My home town or city is:
*
Your answer
My home zipcode is:
*
Your answer
My preferred mailing address is:
Your answer
My preferred telephone number is:
*
Your answer
My preferred email address is:
*
Your answer
My spouse's name is:
Your answer
My child's name is:
*
Your answer
My child's birthdate is:
*
Your answer
My child's school and grade is:
Your answer
I have other children as well: (please list names & ages)
Your answer
Questions about your child and your concerns
The following questions are optional.
My child is seeing a therapist:
yes
no
in the past but not right now
My child takes medication:
yes
no
medications are or were prescribed but my child is not taking them at this time
I think my child should be evaluated for medication help
Other:
I am contacting you for: (check all that apply)
Help with my child's behavior at home
Help for my child's behavior at school and/or with other children
Help for my teenager's behavior at home
Help for my teenager's school problems
Help for my child or teenager to deal with depression, anger, or anxiety problems
Help for my child and the family due to family changes (recent move, illness, divorce, etc.)
Help for my child for problems related to adoption
Help for my child for problems related to trauma
Help for trouble related to alcohol, drugs, internet, etc.
I got your name from:
a friend
another therapist
the internet
Other information is being sent to you in a second email
You will get a second email with a PDF file that has my policies and procedures, so that you can learn about confidentiality, fee policies, scheduling issues, etc., before we meet.
I will go over these policies with you when we meet, and answer any questions you have before we begin to discuss any important information.
Please feel free to get in touch with me by phone or email prior to our first meeting if you have questions or concerns.
Charlie Glazier LICSW - 617-645-5048
charles@thewaytobetter.com
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
