Name of person wanting to join the group:

First Name *

Last Name *

Date of birth *

Names of Parents / Caregivers if patient is a minor

Email *

Phone *

Please Note: If the patient is a minor, we will need consent from both parents/caregivers. We will also need a copy of the custody agreement/divorce decree before we can start services.

What group are you interested in?

Group Play Therapy Ages 4-6

Brick Builders Ages 6-8

Tween Expressive Arts Ages 9-12

Teen Social Skills Group Ages 13-17

Child-Parent Relationship Therapy (for Parents)

Is there anything else you would like us to know before we reach out to connect with you?

How did you hear about us? *

I understand that communications via SMS and email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Reach Counseling staff will coordinate our initial phone consult, in which I permit to leave me a message at the phone number and email address provided.