Parent / Caregiver Name
*
First Name
Last Name
Phone
*
Country
(###)
###
####
Email
*
City, State you are located in (we have clinicians licensed across the country)
*
Child / Patient Name
*
First Name
Last Name
Age of Child / Patient
Under 2
Age 2-4
5-7 years old
8-10 years old
11-15 years
Late teen / Adult (SM Only)
My child / the patient is struggling with these things below (check all that apply)
*
Request Treatment Type
*
Check the appropriate types of treatment you have been recommended to participate in.
If referred to a specific therapist, check their name here:
*
Session Times
*
I understand that afternoon session times are limited and some sessions may have to occur during the school day.
Referral source
*
Name of referring provider or individual:
Insurance acknowledgement.
*
Child and Family Therapy Collective does not accept insurance or participate in any insurance plans. Payment is accepted in cash/credit card at the time of treatment. We do offer superbills for you to submit for out-of-network reimbursement.
Membership Model
*
I acknowledge that CFTC functions with a membership model. Additional information will be provided to me before treatment begins.
Patient Relationship
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Completion of this form does not constitute a confidential relationship. Clinical care begins at the intake session.
Communication Acknowledgement
*
By completing this form, I understand that CFTC will communicate with my via email regarding services.
Email List
*
Our newsletter includes information about events, tips and tricks, and other content.
We recommend the email list for all families as we announce upcoming group and learning opportunities here.
Would you like to be added to our email list to receive our newsletter?
How did you hear about us?
*
Google Search
PCIT Provider List (PCIT.org)
Selective Mutism Association Provider List (selective mutism.org)
Professional / Pediatrician
Friend / Parent / Previous patient
School / Teacher
Instagram / Social Media
Other
