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Contact Form- For Clients under 18 years old
**If you do not get a response in 3-5 business days please check your spam/junk folder before following up.**
*
Indicates required field
Potential Client's Name
*
First
Last
Legal Name (if different)
*
First
Last
Email
*
Can we contact you and use your name via phone?
*
Select
Yes, you can call but do not use my name for safety reasons
No, email communication only
Yes, you can call & use my name
This option is to help protect our more vulnerable potential clients.
Can we text you?
*
Yes
No
Text reminders ONLY
Please note, we cannot do therapy via text. Texting is for basic communication ONLY
Phone Number
*
Clients Pronouns
*
If you feel comfortable, please write which pronouns we should use when addressing you.
Is the potential client willing to participate?
*
Select
Yes, I, the client am willing to participate
Yes, I am inquiring on behalf of the client and they are willing to participate.
Kind of, they are open to hearing more before making a decision
No, I am inquiring on behalf of the potential client but they either do not know or are not willing.
No but they are court mandated
This section will be confirmed before therapy is started. Clients must be willing to participate in order for therapy to work to its fullest. Hesitation is normal but we want to make sure we are respecting autonomy as well.
How did you hear about us?
*
Select
Social Media Ad
Google Search
Psychology Today
Therapy Den
Inclusive Therapists.com
Friend/ Family referral
Health Care Professional Referral
TAC referral
Other
Why? This helps us see where our clients are finding us so we can determine where to place our resources to help become more visible to potential clients who may be looking for services like ours.
Parent/ Legal Guardian's name:
*
First
Last
Parents and guardians cannot reachout on behalf of their child if they are over 18 years old. The prospective client needs to be present during the phone consultation.
What is your relation to the client?
*
Select
The potential client
Custodial Parent
Non-Custodial Parent
Guardian
Foster parent
Case worker
Other, explain
If selected "other" to relationship, define here
*
Preferred Days To Be Seen
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
No preference
Select the days you are able to have sessions on. Select all you could make work. This helps us connect you with a therapist who is available when you are.
Preferred times to be seen
*
Mornings (before 11)
Afternoons (11-4)
Evenings (5-8)
No preference
Select the days you are able to have sessions on. Select all you could make work. This helps us connect you with a therapist who is available when you are.
Therapist Preference?
*
Select
No Preference, soonest availability
Tayler Clark, LCSW
Maddie Noorlander-Bury, LPC-IT
Kaity Anderson, LPC
Heidi Smaradottir, LPC, MFT-IT
Amanda Mathy, LPC-IT
Ousia Moon, Clinical Intern
Ashley Trapp, Clinical Intern
Preferred session environment
*
Choose one
Telehealth (virtual)
Office- In Person
No Preference
Hybrid
Primary Address
*
Line 1
Line 2
City
State
Zip Code
Country
Briefly Explain Reason for Reaching Out
*
This section helps our schedulers determine which therapist(s) could be a great match for you. Please avoid going into too much detail. However, explain what focuses you would like the therapist to have, (i.e. gender affirming, Neurodiveristy affirming & BIPOC experience affirming care)
Submit
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Work with us!
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