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Psychotherapy Booking Form
First name
*
Last name
*
Email
*
Phone
*
Birthday
*
Day
Month
Year
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Are you applying for yourself or a minor?
*
Myself
Minor (16+)
Minor First Name
*
Minor Surname
*
Minor Address
*
What is your relationship to the minor?
*
Does the minor have any medical conditions/ mental health diagnosis/ disabilities or anything else health related I need to be aware of?
*
Give a brief description of the issue.
*
Is the minor aware that this referral is being made?
*
Is the minor/family currently under the care of TUSLA?
*
If the booking is accepted then a detailed intake form will be sent to the parent(s)/guardian(s). In the meantime is there anything else you feel I should be aware of?
*
Do you have any medical conditions/ mental health diagnosis/ disabilities that I should be aware of?
*
Have you ever or do you currently suffer from any issues around additiction (alcohol, drugs, gambling, gaming etc)?
*
Please give a brief description of the issue.
*
Is there anything else you would like to share?
What days and times are you available to attend sessions?
*
Submit
First name
*
Last name
*
Email
*
Phone
*
Birthday
*
Day
Month
Year
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Are you applying for yourself or a minor?
*
Myself
Minor (16+)
Minor First Name
*
Minor Surname
*
Minor Address
*
What is your relationship to the minor?
*
Does the minor have any medical conditions/ mental health diagnosis/ disabilities or anything else health related I need to be aware of?
*
Give a brief description of the issue.
*
Is the minor aware that this referral is being made?
*
Is the minor/family currently under the care of TUSLA?
*
If the booking is accepted then a detailed intake form will be sent to the parent(s)/guardian(s). In the meantime is there anything else you feel I should be aware of?
*
Do you have any medical conditions/ mental health diagnosis/ disabilities that I should be aware of?
*
Have you ever or do you currently suffer from any issues around additiction (alcohol, drugs, gambling, gaming etc)?
*
Please give a brief description of the issue.
*
Is there anything else you would like to share?
What days and times are you available to attend sessions?
*
Submit
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