Phone Therapy Intake Form

First, please complete the form in its entirety and one of our intake counselors will contact you within the times you have specified.

A ten minute consultation will follow at no cost to you to best determine the course of action for your situation . You will also receive an email concerning your appointment time once it’s scheduled.

Your Name: *

State:

Time Zone:

Email address: *

Phone: *

number where you prefer to be contacted for therapy

When is the best time(s) to reach you?: *

Other:

Days of the week that are best for you:

Second choice day of week and time (minimum 2 hour window):

Children’s names and ages:

Briefly describe family dynamic/who lives in the home and any major changes in last six months (divorce/death/move):

Reason for contact / how can we help you:

(PLEASE describe the problem as specifically as possible i.e., not a general statement ―My child is always acting out‖ instead ―My son yells and sometimes hits whenever I give him a direction. This occurs about 50% of the time‖.)

What have you already done to try to solve the problem? What particularly has helped and also what has failed to help?:

Do you have specific questions that you would like answered as a result of the phone therapy?:

Any relevant diagnosis for your children or family members. Also include medications if prescribed:

How did you learn about us?:

** Once you’ve completed the intake form, an intake counselor will call you to schedule your session.

general terms and conditions

I UNDERSTAND AND AGREE TO THE TERMS OF USE AGREEMENT AND CHOOSE TO ACCESS SERVICES.

Parent Help Live

Phone Therapy Intake Form