R.E.A.C.H. Family Therapy

Complete the form below so that we can schedule your 15-minute complimentary parent consultation phone call.

Your Name

Person filling out this form

First Name

Last Name

Your Email Address

Best Number to Contact You

(###)

###

####

Client's Name

(This is the person who will be receiving therapy services)

First Name

Last Name

Client’s Date of Birth

YYYY

Client’s Current Age

How did you hear about our services?

Please choose an option from the drop down menu:

If you answered FRIEND/OTHER to the question above, please specify:

What is the current biggest challenge that you are seeking therapy for?

What would you like to accomplish through therapy?

What would you like to see change?

What supports are you most interested in exploring?

Check all that apply:

Individual Counseling (Client and Therapist Only)

Family Counseling (Client + Other Family Members and Therapist)

Parenting Only (Parents of Client and Therapist w/Out Client Present)

Group Therapy (Client + Other Participants and Therapist)

I’m Not Sure and Would Like to Discuss the Options

What is the best way for us to schedule a 15-minute consultation call with you?

Mrs. Schlett will reach out to schedule a 15-minute phone consultation with you via email, text, or phone call.

Is there anything else you would like us to know before we reach out to you?

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