Schedule Now Is this scheduling request for a child under 18 years of age or for a family?* Yes No Important!!! Unfortunately, our office is no longer providing adult therapy services. We will continue seeing children, adolescents and families. If you need adult, mental health, or substance abuse services, please go here.Child's Name* First Last Child's Date of Birth* MM slash DD slash YYYY Name of Person completing Form* First Last What is your relationship to the Child?* Biological or Adoptive Parent Step Parent Foster Parent Other Guardian Other Phone*Email* Services Requested Individual Therapy Group Therapy Family Therapy Assessment Only If I am currently unable to take new clients--would you want to be added to a waitlist?* Yes No Our office only has one provide (C.J. Quick, LPCC-S, LMFT, RPT-S); however, there are two other therapists with agencies in the same office. If they are taking new clients and C.J. is not, would you want us to share your contact information with them? No, do not share my information. Yes, please share my information with Beth Brown, LPCC-S, RPT-S (Better Beginnings Counseling) Yes, please share my information with Sarah Reynolds, LCSW (Building Foundations Counseling and Consultation) Yes, please share my information with Beth Brown and Sarah Reynolds Please tell me your reason(s) for seeking therapy...Is there an ongoing or upcoming court case related your child? Yes No Unsure What is the current custody situation for your child? Are all parents/guardians aware and in support of this scheduling request?Type of Insurance?*Any additional Requests or Information you'd like me to know...*