Your Phone Number *

(###)

###

####

Client Name *

Name of the person who will be receiving our services

First Name

Last Name

Client Date of Birth *

MM

DD

YYYY

Which counselors are you/your teen interested in working with? *

Not all counselors may have immediate availability but we will try and match you with your preferred counselor where possible.

Kathryn (Waitlist Open - not accepting new clients)

Amanda (Waitlist Open - not accepting new clients)

Devon (Waitlist Open - not accepting new clients)

Kelsey (Waitlist Open - not accepting new clients)

Eden (Waitlist Open - not accepting new clients)

Justine (Waitlist Open - not accepting new clients)

James (Waitlist Open - not accepting new clients)

Aleen (Waitlist Open - not accepting new clients)

Alaina (Waitlist Open - not accepting new clients)

Brenna (Waitlist Open - not accepting new clients)

No Preference

What form of session would you be interested in? *

In-person

Virtual

Either in-person or virtual