Initial Contact Form

Client Name*

First Last

Age*

Please enter a number from 0 to 100.

Client Gender*

Name of School or Occupation

Parent or Other Contact Name (If Applicable)

First Last

Relation to Client (If Applicable)

Phone #*

Email*

Referral Source*

Would you like to contact a specific provider?

Which services are you interest in?*

Reason for seeking services*

Previous Diagnosis (If Applicable)

Is interest in our services in relation to any court-related issues?*

If parents are separating or divorced, are both parents in agreement to access our services?*

Additional Comments

Out-of-Network*

By checking this box, I understand that Spectra Therapies is out-of-network and does not accept any insurance. More information on how to find out about your insurance out-of-network benefits is provided under About Us.