Contact Us Name of Client (Minor) * First Name Last Name Pronouns (Client/Minor) Age/Date of Birth of Client (Minor) Name of Parent/Guardian * First Name Last Name Parent/Guardian's Email * Parent/Guardian's Phone Number * (###) ### #### Additional Contact Information (Email/Phone) If there is an additional parent/guardian/family member you would like us to communicate with, please share their contact info below. Preferred Contact Method Phone Call Text Email What is your therapist's name? What year in school is the client? * Please note we currently only assess individuals up to age 25. Has the client participated in an evaluation before? Yes No Preferred Office Location * Please note: we currently only offer assessments at our Apex office, but are looking to expand in the future. Your feedback is appreciated 🙂 Downtown Raleigh [A] East Raleigh [A] West Raleigh [A} North Raleigh [A} Midtown [A] Garner [B] Knightdale [B] Virtual [B] Chapel Hill [B] Apex [C] North Durham [C] South Durham [C] Southern Village [C] Pittsboro [C] What are the client's current areas of concern? Please select all that apply. * Academic skills and learning Behavioral (e.g., attention, hyperactivity, impulsivity, executive functioning, aggression, etc.) Cognitive abilities Emotional (e.g., anxiety, depression, emotion regulation, withdrawal, self-esteem, etc.) Early development and delays Language and communication Social skills and peer relationships Adaptive skills (e.g., self-care, daily routines, navigating school/community, etc.) Other concerns (Please describe in Message box below.) Are you (the parent/guardian) interested in learning more? Please check all that apply. Parenting strategies Psychotherapy services Community resources and related service providers (i.e., occupational therapy, speech-language therapy, physical therapy, tutoring, etc.) School-based supports (e.g., special education/IEP, Section 504 plan, intervention, specialized programs, etc.) Unsure/I am interested in learning more. (Please describe in Message box below.) Message Thank you! We have received your request. You should hear back within 3 business days.
