Name of person competing this form: *

First Name

Last Name

Child's name *

First Name

Last Name

How did you hear about Reach Counseling? *

Friend/Word of Mouth

School

Psychology Today

Internet Search

Doctor or Professional

Current client

Other

I agree to the privacy policy below: *

I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Reach Counseling will coordinate the Parent Intake, in which I give permission to leave me a message at the phone number and email address provided.

I Agree