Contact us Name * First Name Last Name Email * Reason for seeking consulation * Reason for seeking consulation Mental Health (Depression, Anxiety, PTSD, Panic attacks, Aggression, ADHD, Autism) Substance use Anything else Has your child ever been diagnosed with a psychiatric condition or received mental health treatment? Never Therapy Medications Hospitalization Has your child ever had any thoughts of self-harm, suicide or shown self-injurious behaviors? Never Yes Does your child have any medical, neurological, or developmental conditions- such as seizures, head injuries, heart conditions (including murmurs), asthma or other diagnosis? No Yes Are there any current or past legal issues, school concerns (such as IEPs, suspensions), CPS involvement, or guardianship arrangements we should be aware of? Yes No Thank you!