We’re listening!

Phone *

(###)

###

####

Are you using insurance? *

Yes

No

What kind of Therapy? (select all that apply) *

Play Therapy

Counseling/Talk therapy

Occupational Therapy

EMDR

Diet & Nutrition Services

Couples Therapy

Teen Struggles

Parent Coaching

Executive Functioning

Mental Performance Coaching

Health and Wellness Coaching

Yoga/Breath Work

ADD/ADHD/ASD Assessments

Do you (or your child) struggle to stay still? *

Fidgeting, shaking legs, need to move around, etc.

Yes

No

N/A

Do you (or your child) have sensitivities to foods, textures, or loud or repetitive noises? *

Yes

No

N/A

Do you struggle with any of the following? *

select all that apply

Time management

Task Prioritizing

Forgetting Deadlines

Difficulty Making Decisions

N/A