Parent / Caregiver Name *

First Name

Last Name

Phone *

Country

(###)

###

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Child / Patient Name *

First Name

Last Name

My child / the patient is struggling with these things below (check all that apply) *

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 Therapy Service *

Check the appropriate types of services and/or treatment you are interested in.

Individual Therapy

Parent Child Interaction Therapy (PCIT)

Selective Mutism Treatment (PCIT-SM)

Cognitive-Behavioral Therapy (CBT)

Parent Management Training (PMT)

Social (Pragmatic) Communication Therapy

Speech and Language Therapy

Group Therapy

Request Testing Service *

Check the appropriate types of services and/or treatment you are interested in.

ADHD Testing

Autism Testing

Gifted Testing

Psychological Testing

Speech and Language Testing

Multi-Disciplinary Testing

No testing Needed

If referred to a specific therapist, check their name here: *

Referred to the practice, please match me with the best therapist for us.

Eleanor Ezell, LCSW

Andrew Rozsa, PhD

Charlotte Keeney, LCSW

Kristin Mathis, MS, CCC-SLP

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.

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.