Please note we may have a short waitlist and will add your information to the waitlist if needed. *

Yes I would like to be added to the waitlist.

No I do not want to be added to the waitlist.

Your Information

First Name *

Last Name *

Email *

Phone *

Child Information (if applicable)

Child's First Name

Child's Last Name

Child's Age

Please select the services you are interested in:

Therapy Services: *

Individual Therapy (for myself)

Individual Therapy (for my child or someone I know)

Parent Support/Parent Management Training/PCIT

School Consultation

N/A

Evaluation Services :

Mental Health Screening (1 hour)

Diagnostic Evaluation (3 hours)

Comprehensive Psychoeducational or Neuropsychological Testing (12-20 hours)

Reason for Seeking Help

How can we help? What are your primary concerns? Please be as detailed as possible so we can match you with the best clinician for your needs. *

Self-Pay Fees

I understand Tampa Pediatric Psychology does not accept insurance and I am responsible for all self-pay fees.

Scheduling

We do our best to accommodate requests for in-person and after school therapy; however, we cannot guarantee a spot. Many kids leave school early or meet during the day to make it work.

I'm ok with Telehealth therapy.

I prefer in-person services if available.

Do you have a specific provider you wish to work with?

Match me with the best fit

Dr. Melissa Miranda

Dr. Morgan Lago

Dr. Kim Knap

Doctoral Practicum Student (reduced fee)

Dr. Kristin Edwards (evals and parent consultation only)

Best way to contact you:

Text

Call

Referral Information

How did you find us? *

Messaging Consent

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