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:
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:
My child takes medication:
I am contacting you for: (check all that apply)
I got your name from:
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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