Parent or Guardian Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
MM
DD
YYYY
Phone
*
(###)
###
####
Is this your home, work, or mobile number?
*
Please select
Home
Work
Mobile
Can we leave messages at this number?
*
Email Address
What is your preferred method of contact?
*
Any
Phone
Email
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you or anyone coming to sessions with you have mobility issues which would make it challenging to access our office, which is up a flight of stairs?
*
Yes
No
If Yes, please provide a brief description below.
Approximately, when did these concerns begin? How long has your child been experiencing these concerns?
*
Eating and Sleep Habits / Issues:
Extra-Curricular Activities:
Child’s Strengths:
Is your child currently taking any medications prescribed to address their concerns?
*
Please select
Yes
No
Is your child having any concerns with suicide and/or self-harm:?
*
Please select
Yes
No
If Yes, when?
If you're working with multiple helping professionals, please select the most recent.
If Yes, what other helping professionals have you worked with related to your child's concerns?
Please check all that apply.
If "Other", please provide a brief description below.
Is there anything else you think we should know or would like to share with us?
What days are you available for appointments?
*
Please check all that apply.
What times are you available for appointments?
*
Please check all that apply.
How do you wish to receive appointment reminders?
*
Reminders are sent 48 hours before your scheduled appointment. Please select one option.
How did you find out about New Roots Therapy?
*
Please select
Google search
Therapist listing site (e.g. Psychology Today, Theravive, Goodtherapy.org)
Helping professional (e.g., doctor, other therapist, etc.)
Family/friend
Other
If Other, please provide a brief description below.
Will you be submitting claims to an insurance provider for reimbursement?
*
Select all that apply. Please check with your insurance provider to confirm the details of your coverage prior to your first session. You can refer to our 'Guide To Understanding Your Insurance Coverage' through our 'Services' page for more information.
A credit card number is required to reserve appointment times. We kindly ask that you have a credit card ready when we contact you to reserve your appointment.
*
