Request appointment | Lifespan Wellness

Who are you seeking care for?

Myself My Child

What kind of care is being sought?

Individual Therapy (for Myself) Individual Therapy for my Child

Please indicate your primary reason for seeking Individual Therapy for yourself or your child at this time (select all that apply):

Please briefly describe your main goals, what you hope to achieve or learn through therapy?

Within the last 6 months, have you or your child engaged in any of the following mental health care services?

Psychiatry or Medication management Individual Therapy Partial or Intensive Outpatient Treatment Residential Treatment Inpatient Hospitalization Family Therapy

For child clients: What is the current marital/relationship status of the child's parents?

To provide therapy to a minor, we legally require the authorized consent of all legal guardians. If parents are divorced, separated, or co-parenting, we must verify custody arrangements and obtain signed consent from all required parties before our first session can begin.

Married or Together (Co-habitating) Divorced Seperated Never Married/Co-parenting Single Parent (No second legal guardian involved; paperwork must be provided)

For child clients: What is the legal custody arrangement for the child?

To provide therapy to a minor, we legally require the authorized consent of all legal guardians. If parents are divorced, separated, or co-parenting, we must verify custody arrangements and obtain signed consent from all required parties before our first session can begin.

Joint Legal Custody (Both parents share decision-making power; both must sign consent forms) Sole Legal Custody (One parent holds all decision-making power; we will need a copy of the court order for our records) No formal court agreement is in place (Both biological parents must sign consent)

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