What type of services are you seeking? *

Check all that apply.

Counseling/Therapy

Parenting Support/Coaching/Parent Management Training/PCIT

Professional Services (workshops, trainings, presentations, etc.)

Educational Advocacy

Evaluation/Assessment

Unsure

If interested in evaluation/assessment services, which type of evaluation are you interested in? *

Check all that apply.

Academic/Learning

Attention Deficit Hyperactivity Disorder (ADHD)

Behavior

Autism Spectrum Disorder (ASD)

Mood

Developmental

Gifted

Homeschool

Other

Unsure

I'm not interested in an evaluation/assessment.

Primary Contact Name *

First Name

Last Name

Primary Contact Phone *

(###)

###

####

What is the best way for us to reach you? *

Phone

Email

What is your preferred location for services? *

Check all that apply.

First Available

St. Petersburg (Tyrone)

Tampa (Hyde Park/UT)

Telehealth

What day(s) of the week are you available for sessions? *

Check all that apply.

First Available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What are your preferred appointment times? *

Check all that apply.

First Available

Early Morning (7a - 9a)

Morning (9a - 12p)

Early Afternoon (12p - 2p)

Late Afternoon (2p - 5p)

Evening (5p - 8p)

How did you hear about us?

Check all that apply.

Internet search

Physician

School/Teacher

Friend/Colleague

Presentation/Training

Social Media

Other