Let’s work together.

Please fill out the information below to give me a brief idea of what your concerns are and what type of help you are looking for. Once I receive your intake I will be in touch within 1 business day. I look forward to connecting with you!

Your Name (Parent)

First Name

Last Name

Your Child's Name

First Name

Last Name

Your Child's Gender Identity and Preferred Pronouns

(e.g., he/him, she/hers, they/them, he/they)

Email

Phone

(###)

###

####

What services are you interested in?

Please select all that apply.

Individual adolescent counseling

Parent coaching

Educational consultation

When are you hoping to begin services?

MM

DD

YYYY

How did you find Teen Teletherapy Space?

Message

If you would like to add any additional details about your primary concerns, please use the space below.