Client Full Name
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Client Date of birth
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Client Age
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7 yrs. and under
7-12 yrs.
12-17 yrs.
18-25
26 and over
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Client Gender Identity (Please check all that apply)
Male/Boy/Man
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Trans
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Client Sex Assigned at Birth
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Client Pronouns (please check all that apply)
She/her/hers
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They/them/theirs
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Caregiver Full Name (if applicable)
Primary Email Address
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Primary Phone Number
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Messaging Consent
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State of Residence
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Alabama
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Ohio
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South Carolina
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Texas (specifically Houston area)
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Washington, D.C.
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Timezone (TCC)
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Pacific Timezone (PST)
Mountain Timezone (MST)
Central Timezone (CST)
Eastern Timezone (EST)
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What services are you seeking? Please check all that apply.
*
Therapy for my child
Therapy for myself (adult)
Family Therapy
Parent-Child Interaction Therapy (PCIT)
ADHD Evaluation for child
ASD Evaluation for child
ADHD Evaluation for adult
ASD Evaluation for adult
Forensic (current or potential court involvement)
Other testing not listed
Unsure (please provide more info below)
Additional Information
What location would you prefer to receive services?
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Please select
Virtual
River Oaks
River Oaks and virtual hybrid
The Woodlands
The Woodlands and virtual hybrid
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Referral Source
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Google
Referring physician
Trusted friend
Facebook
Psychology Today
Instagram
Attorney
PCIT.org
Other
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Specific referral name
*
Has the client had any prior treatment or diagnoses?
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Is there any family custody dispute? Any current or potential court involvement? If yes, please add as much relevant information as possible in the Additional Information box.
*
Yes
No
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If applicable, please upload the most recent Divorce Decree/Custody Agreement to help us get you setup more quickly.
Do you have Modern Health or Lyra benefits provided by your employer?
*
Please select
Modern Health
Lyra
No
Not sure
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I understand that all services conducted by Thriving Child Center are private pay and that Thriving Child Center is out-of-network will all insurances. I understand that Modern Health and Lyra are the only EAPs that Thriving Child Center accepts.
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