Initial Contact Form Initial Contact Form Child's Name * Child's Age * Parent's Name * Parent's Email * Parent's Telephone CLINICAL INFORMATION Source of referral Child’s symptoms of concern When did these symptoms first start? Has your child received treatment for these symptoms? Yes No If yes, who provided treatment? PAYMENT INFORMATION Would it place a financial burden on you or your family to pay for psychological services out-of-pocket? Yes No Do you have “out-of-network benefits” for mental health services through your insurance? Yes No Do you feel comfortable submitting a claim to your insurance company yourself for possible reimbursement? Yes No Scheduling Appointments Monday Morning Afternoon Tuesday Morning Afternoon Wednesday Morning Afternoon Thursday Morning Afternoon Friday Morning Afternoon Saturday Morning Afternoon Would you be interested in conducting some sessions remotely (i.e., via an internet-based video platform)? Yes No Thank you for taking the time to respond to these questions. Please note additional questions you may have for me below. I will provide a response within 7 working days. If you are human, leave this field blank. Submit
