Full Name *

Child’s Name

Phone *

Address

Postal code

Email *

Spouse / Co-Parent Information (Optional)

Name
Phone
Email

Which location are you wanting services? *

Provo Location

Tooele Location

Child's Age

Relationship to child

*If the child’s biological parents are separated/divorced, please read our Divorce and Custody Matters document to better understand if we are a good fit for your family’s needs

What is the status of the biological parents of the child? *

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Provide at LEAST 3 times you or your child are available for counseling. *

What is the best way to contact you? *

Phone

Which time(s) would you prefer for us to contact you about your inquiry?

Morning - 9:00 AM - 12:00 PM

Afternoon - 12:00 PM - 4:00 PM

Evening - 5:00 PM - 7:00 PM

Are you or your child currently on Medicaid? *

Yes

Please note: Currently we do not accept Medicaid. Additionally, since we do not accept Medicaid, it is illegal for us to accept out-of-pocket payments from Medicaid members. We recommend finding a provider within the Medicaid Network.

Have you reviewed our OUT-OF-NETWORK/PRIVATE PAY policy? *

Yes

How did you hear about us? *

Briefly describe the issue(s) you would like us to work on *

Email and SMS Text Message Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Power Within Child Therapists and/or office staff communicating with me via email or text message

You agree to receive informational messages (appointment reminders, account notifications, etc.) from Power Within Child Therapists. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at [email protected]. You can opt out at any time by replying STOP.
See Privacy Policy & Terms and Conditions for more.

Once you click the submit button, you will have the opportunity to schedule a Free Consultation. Otherwise, a member of our team will reach out to you within 24 hours during business days