"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 Address *
Child's Date of Birth *
Child's Medical Assistance Number
Primary Medical Insurance Company *
Insured Name *
Insured Date of Birth *
Referral Source *
Diagnosis (if known)
Adjunctive Services (Speech, OT, PT)
Are you currently enrolled in HIPPP? *
Do you currently receive BHRS? *
If so, with whom?
Comments or Questions

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