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)
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ADHD
Aggression
Anxiety
Autism
Big emotions
Defiance / Oppositional behavior
Difficulty listening
School refusal (difficult getting to school, can be for many reasons)
Selective Mutism
Social engagement
Social pragmatics
Speech and Language
Tantrums
Other related behaviors
Obsessive Compulsive behaviors
Request Service Type
*
Check the appropriate types of services and/or treatment you are interested in.
Parent Child Interaction Therapy (PCIT)
Selective Mutism Treatment (PCIT-SM)
Cognitive-Behavioral Therapy (CBT)
Parent Management Training (PMT)
Social (Pragmatic) Communication Therapy
ADHD Testing
Autism Testing
Speech and Language Testing
General Psychological Testing
Group Therapy
If referred to a specific therapist, check their name here:
*
Eleanor Ezell, LCSW
Andrew Rozsa, PhD
Kristin Mathis, MS, CCC-SLP
Charlotte Keeney, LCSW
Referred to the practice, please match me with the best therapist for us.
Session Times
*
I understand that afternoon session times are limited and some sessions may have to occur during the school day.
I understand sessions may be 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 via credit card on file at the time of treatment. We do offer superbills for you to submit for out-of-network reimbursement.
I understand that CFTC does not accept insurance.
Multi-Disciplinary Monthly Membership Model
*
I acknowledge that CFTC functions with a membership model that is billed monthly to support multi-disciplinary care. Additional information will be provided to me before treatment begins.
I understand that CFTC bills a monthly multi-disciplinary fee in addition to individual session fees.
Patient Relationship
*
Completion of this form does not constitute a confidential relationship. Clinical care begins at the intake session.
I understand clinical care does not begin until an intake session occurs.
Communication Acknowledgement
*
By completing this form, I understand that CFTC will communicate with my via email regarding services.
I understand that CFTC will communicate via email for 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?
Yes, I want to receive emails.
No, I do not want to receive emails.
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