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Therapy Appointment Request Form

It all starts with you! Contact us today!

This form is intended for female children/teens only

Parent's First and Last Name

Parent's Phone Number *(format: no dashes)*

Parent's Email

Preferred Method of Contact (call, text, email, or any method)

Child's First and Last Name

Client's Age

Primary Insurance (scroll to view all)

Secondary Insurance (if applicable) (scroll to view all)

Member ID #/Medicaid ID # From Insurance Card

Location

Clients have to be located in either South Carolina or Connecticut to receive therapy services virtually.

Depending on the age of the client and presenting challenges, therapist may recommend in person after assessment.

Do you currently have any ongoing child custody/vistation cases or legal proceedings related to the care of your children

Do you currently have any open cases with the Department of Social Services (DSS)? or Have you ever been involved in a DSS case that is still ongoing?

Therapist Preference

Note: Each Therapist wait times vary.

Best Day(s) for Therapy (check all that apply) * Required

Monday

Tuesday

Wednesday

Thursday

Friday

Best Time(s) for Therapy ( check all that apply) * Required

11 AM- 12 PM

12 PM - 1 PM

1 PM- 2 PM

2 PM- 3 PM

3 PM - 4 PM

4 PM- 5 PM

Please be aware that most afterschool times more than likely will have a wait time, please ensure that all times and days are selected that client is able to come for therapy. Medical excuses are given for any appointments scheduled during school hours. We will inform client or parent with the waitlist time during the initial assessment.

Presenting Challenges/Reason for seeking therapy (What concerns are you hoping for therapist to address with child/teen? (Check all that apply) * Required

Anxiety or excessive worry

Depression or sadness

Anger or emotional outburst

Difficulty with attention or focus (e.g., ADHD concerns)

Behavioral challenges at home or school

School refusal or academic stress

Peer problems or social difficulties

Bullying (as target or aggressor)

Family transitions (e.g., divorce, relocation, new sibling, new school)

Grief or loss

Trauma or difficult life events

Sleep problems or nightmares

Self-esteem or confidence issues

Gender identity or LGBTQ+ support

Suspected developmental concerns (e.g., autism spectrum)

Self-harm or concerning behaviors

Sucicidal thoughts or concerning behaviors

Temper Tantrums

Defiance or oppositional behavior

Lying, stealing, or rule-breaking

Trouble following directions

Risky or impulsive behavior

School refusal or avoidance

Withdrawal or isolation

Peer conflict or exclusion

Difficulty making or keeping friends

Social anxiety

Exposure to domestic violence

Autism spectrum or sensory issues

Seperation anxiety

Identity Crisis

Academic pressure or school stress

Sibling Conflict

Is your child/teen currently experiencing any of the following? (Check any that apply. This information helps us understand how to support you best * Required

Active thoughts of self-harm

Active thoughts of suicide

Current or recent crisis (within the past 72 hours)

Active self harming/self injurious behaviors

None of the above

This form is not monitored 24/7. If you are in immediate danger or experiencing a crisis, please contact 911 or the National Suicide & Crisis Lifeline at 988.

Add anything else you’d like us to know about your child or your goals for therapy:

I give consent to being contacted via call, text or email in reference to this therapy appointment request. I understand that this form is not for emergencies, and I should go directly to the nearest emergency room or call 911 for emergencies. * Required

Accept

If you have any technical difficulties with the submission page, give us a call at 864-332-9956

Address

330 Pelham Road, Ste. 210B

Greenville, SC 29615

Phone and Fax

Phone: (864) 332-9956

Fax: (864) 686-5516

Email

info@truetoherselftherapy.com

Connect

Office Hours

Monday - Friday

11 AM - 5 PM

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