Free 15 Minute Consultation Request
I use a private Zoom Meeting Room
Full Name of Potential Client
*
First Name
Last Name
What is the client's age?
*
Name of parent / guardian and relationship
Contact Phone Number for texts
*
Making Sure...This Phone Number Can Receive Texts.
Please Select
Yes
No
Check the psychiatric conditions that apply to you or a loved one
Anxiety or Panic
ADHD
Anger or Irritability
Bipolar
Depression
Eating Disorder
Schizophrenia
OCD
Autism Spectrum
Behavior Issues
Other Psychiatric Issue(s):
Any Other Specific Questions?
Can you use or download the Zoom App on your phone or computer?
*
Please Select
Yes - I have it and know how to use.
No - But I can download it and use it.
No - That option won't work for me. (Unfortunately, I only use Zoom.)
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