Thank you for your interest in an evaluation from one of our behavioral health clinicians. Please be advised this is NOT for emergency behavioral health concerns. If you are experiencing an emergency, please call your primary care physician or go to the nearest emergency room. Please allow 5-6 minutes to fill out the information below. Once completed, one of our behavioral health care coordinators will reach out to you to coordinate an intake appointment within 72 hours of receipt of this form. For a limited time through June 30, your child’s initial screening and evaluation are complimentary. Teletherapy sessions start at $125. We will provide you with a receipt to submit to your insurance for reimbursements. We look forward to speaking with you soon.

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* 1. Reason for visit request

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* 2. How did you hear about us?

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