Let’s Get Started Please enable JavaScript in your browser to complete this form.Full Name of New Client Needing Appointment *FirstLastFull Name of Parent or Legal Guardian *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *Phone Number *E-mail *Best Time To Reach You How did you hear about us? *GoogleGoogleFacebookInstagramPhysicianPsychology Today AdOther (Please specify below ...)Describe how you heard from us:What Are Your Preferred Times and Dates to Schedule an Appointment?What Are Your Main Questions or Concerns?Telehealth Sessions Okay? *YesNoDoes the Client Have Medicaid? *YesNoWhat Is the Medicaid ID Number? (if no Medicaid, type in None) *Does the Client Have Private Health Insurance? (we are unable to accept Health insurance and Medicaid dual insurance plans) *YesNoName of the Private Health Insurance *Anthem Blue Cross Blue ShieldCignaUnited Healthcare/UMR/OptumEmployee Assistance ProgramOtherNoneFor insurance clients only: are you interested in learning more about the KidStuff CARE Discount Program?YesNoSubmit