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.
My preferred prefix is:
Clear selection
My first name is: *
My last name is: *
My preferred nickname is:
My birthdate is: *
My home street address is: *
My home town or city is: *
My home zipcode is: *
My preferred mailing address is:
My preferred telephone number is: *
My preferred email address is: *
My spouse's name is:
My child's name is: *
My child's birthdate is: *
My child's school and grade is:
I have other children as well: (please list names & ages)
Questions about your child and your concerns
The following questions are optional.
My child is seeing a therapist:
Clear selection
My child takes medication:
Clear selection
I am contacting you for: (check all that apply)
I got your name from:
Clear selection
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
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