Match With A Therapist

Name *

First Name

Last Name

Consent *

I give my consent for the collection, use, and storage of my personal information as described above.

Phone

(###)

###

####

What services are you interested in? Select all that apply. *

Therapy (child therapy, family therapy, and/or parent coaching)

Psychoeducational Testing

Occupational Therapy

Intensive Support Program

Workshops

I'm not sure

If yes, which professional providers are covered under your insurance?

Check your insurance for the registration title (e.g. psychotherapist, not descriptive terms like psychotherapy).

Registered Psychotherapist

Social Worker - RSW or MSW

Social Worker - MSW only

Licensed Occupational Therapist

Psychological Testing

I'm not sure