PracticeAxis -

Parent/Guardian Appointment Request Form

Please fill out this form if you are requesting an appointment for your child or for someone else for whom you are a guardian. We will contact you soon with next steps to find a therapist. Thank you!

What is your child's first name?*

What is your child's last name?*

Have you already submitted this form for another child, or will you be submitting this form for another child?*

Parent/Guardian's First & Last Name*

What is your email address?*

What is your phone number?*

Preferred Method of Contact*

Enter Your Child's Date of Birth in this format: YYYY-MM-DD*

What is Your Child's Age?*

What is Your Child's Gender Identity?*

What Are Your Child's Preferred Pronouns?

Primary Insurance Provider*

Primary Subscriber*

Primary Subscriber Date of Birth*

Please Enter the Insurance Member ID:*

Secondary Insurance Provider (if applicable)

Secondary Insurance Member ID

Street Address*

City*

State*

Zip Code*

What type of therapy are you seeking for your child?*

Please select your primary reason for seeking therapy for your child:*

Which quality, if any, is most important to you in a therapist?

Please describe in your own words your reason for seeking therapy for your child:*

Preferred Appt Time

Preferred Appointment Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Is this therapy court-ordered?*

Are you open to telehealth?

Yes

No

Please verify your request*