Appointment Request

Name *

Email *

Phone *

Reasons for Initial Visit *

Aggressive Behaviors/ Anger

Anxiety

Blended Family/ Break up / Divorce

Biracial or Race related challenges

Issues in School

Acceptance of Current Diagnosis or Desiring a 2nd Opinion

Developmental Delays

Depression/ Excessive Sadness

Lack of Social Skills

Limited Range of Emotions

Lacking Self Esteem

Oppositional Definace Disorder

Adjustment challeges

ADHD

Truama

Autism Spectrum Disorder (Asperger's type)

Requesting Mental Health Consulting/ Staff training

Job or Employment Issues

Concerns realted to Indpendent living

Other

Refferal *

Provider Preference- Gender, Teletherapy, Tn or Ky *

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