Contact Us

Name *

First Name

Last Name

Phone *

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Name of client, if not calling for self

First Name

Last Name

Primary Condition(s): *

Please check all that apply.

OCD

Anxiety

Specific phobia

Social anxiety

Panic disorder/panic attacks

Generalized Anxiety Disorder

School refusal

Depression

Bedtime and sleep difficulties

Behavior management

ADHD

Autism

Tics/Tourettes

Life stressors & transitions

Parent-child communication

Other

Previous Therapy?

Yes

No

Primarily interested in: *

Individual therapy in-person

Individual therapy online (available to CA residents only)

Individual therapy, either in-person or online

Family therapy

One-time assessment or consultation

Preferred day of the week *

Please check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred time of the day *

Please check all that apply.

Morning

Early afternoon

Late afternoon/early evening

My schedule is flexible.

I have noted my preferences, but I can be flexible if this allows me to start therapy sooner.

How did you hear about Marquis Child Psychology?

IOCDF website

Google

Psychology Today

SPACE

Other online location

Another therapist

My/my family member's doctor

My/my family member's psychiatrist

Family/Friend

Other

Please note that we are out of network with all insurance companies. We can provide you with a receipt (i.e., superbill) that you are welcome to submit to your insurance provider for reimbursement. *

I understand.