Age of Child / Patient *

Child / Patient Date of Birth

Address

Street Address

City

State

Country

Postal Code

If referred to a specific therapist, check their name here: *

Referred to the practice, please match me with the best clinician for us.

Eleanor Ezell, LCSW

Andrew Rozsa, PhD

Charlotte Keeney, LCSW

Kristin Mathis, MS, CCC-SLP

Session Times (required) I understand that afternoon session times are limited and some sessions may have to occur during the school day. *

I understand sessions may be during the school day.

How did you hear about us? *

We would like to thank those who refer to CFTC. Please provide the name of referring provider or individual:

Insurance acknowledgement. Child and Family Therapy Collective does not accept insurance or participate in any insurance plans. Payment is accepted via credit card on file at the time of treatment. We do offer superbills for you to submit for out-of-network reimbursement. *

I understand that CFTC does not accept insurance.

Multi-Disciplinary Monthly Membership Model. I acknowledge that CFTC functions with a membership model that is billed monthly to support multi-disciplinary care. Additional information will be provided to me before treatment begins. *

I understand that CFTC bills a monthly multi-disciplinary fee in addition to individual session fees.

Patient Relationship. Completion of this form does not constitute a confidential relationship. Clinical care begins at the intake session. *

I understand clinical care does not begin until an intake session occurs.

Communication Acknowledgement. By completing this form, I understand that CFTC will communicate with my via email regarding services. *

I understand that CFTC will communicate via email for services.

Email List. Our newsletter includes information about events, tips and tricks, and other content. We recommend the email list for all families as we announce upcoming group and learning opportunities here. Would you like to be added to our email list to receive our newsletter?

Yes, I want to join the village! By clicking “join the village”, I am confirming that I want to receive announcements and updates regarding services from Child and Family Therapy Collective. I acknowledge that receiving the newsletters does not constitute a therapeutic relationship.

No, I do not want to receive emails.

Any questions or additional information we should know: