Please fill out all the required questions. Signatures of both parents/guardians with custody (if applicable) are required so it will be helpful to complete this form together.
In cases of separation or divorce, documentation of custody (parenting plan, etc) of child client will be required to submit electronically. Please have these documents ready to upload from your device before filling out.
Please devote 10-15 minutes to complete forms and upload supporting documents, all in one sitting (additional instructions below). Recommended browser is Google Chrome. Not compatible with Safari browser. When forms are complete, click "Submit" at the bottom of the final page.
Before starting this paperwork, please make note of the following:
A parenting plan is needed, if applicable
If you are applying for our sliding scale counseling fees, documentation of income (recent tax return, W2s, or paystubs from household income) will be required to submit electronically to apply for the sliding scale. These fees are based on income. Please have these documents ready to upload before filling out this form.
If you are not applying for a sliding scale fee based on your income, your fee is $120 per session and you do not need documentation of income to upload to proceed with submission.
Please let us know if you have any questions at email@example.com or call us at 615-591-5262 during business hours.