"Daring to set boundaries is about having the courage
to love ourselves, even when we risk disappointing others."
Brene' Brown
Contact Form

Completion of the contact form allows your child to be reviewed for services in the future. Please specify whether you are looking for BHRS, Individual Therapy, Consultation or Social Skills Group services.

Once you have completed this page, please hit the submit button and the complete button on the following page or your form will not be received.  Please allow a minimum of one week for response.

* Required fields
Name *
E-mail Address *
Telephone Number *
Child's Name *
Child's street Address *
City, State, Zip Code *
Child's Date of Birth *
Child's Medical Assistance Number (10 digit state ID number) *
Does your child have Private Commercial Insurance? *
Private Commercial Insurance Company name
Private Commercial Insurance ID number
Private Commercial Insurance phone number (located on back of Primary Commercial Insurance card for provider services or customer service or mental health)
Referral Source *
Diagnosis (if known)
Does your child receive Early Intervention services? *
Do you currently receive BHRS? *
If so, with whom?
Does your child attend daycare? *
If "Yes" where and what days/times?
Does your child attend a school based program? (preschool/school age) *
If "Yes" where and what days/times?
Does your child have any other regularly scheduled therapy sessions? (Speech, OT, PT) *
If "Yes" what days/times?
Comments or Questions

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Completion of the contact form does not guarantee provision of service.