New Client Inquiry Form - Kids & Teens
Thank you for your interest in Renewed Counseling & Play Therapy! Please fill out the form below with as much detail as possible, and we will reach out to you in August to begin seeing one of our Clinical Mental Health Interns in September. 
Sign in to Google to save your progress. Learn more
Child's first and last name: *
Birthday: *
MM
/
DD
/
YYYY
Parent/Guardian 1 name: *
Parent/Guardian 1 e-mail address: *
Parent/Guardian 1 phone number: *
Parent/Guardian 2 name:
Parent/Guardian 2 e-mail:
Parent/Guardian 2 phone number:
What issues are you hoping to address in counseling? *
Would you prefer to meet in person or virtually? *
In person counseling is recommended for children and younger teens. In person and/or virtual counseling is recommended for older teens.
When is your child available to have counseling sessions?
The more options you choose, the more likely we will have availability to accommodate your schedule.
Morning
Afternoon
Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Before meeting with your child, your counselor will meet with you to have a parent session to gather information and make a treatment plan. This can take place in person or virtually. When are you typically available?
The more options you choose, the more likely we will have availability to accommodate your schedule.
Morning
Afternoon
Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What is the marital status of the child's parents/guardians? *
NC law requires that all legal guardians provide consent for a child to receive counseling services. If there is a custody order in place, Renewed Counseling is required to have this order on file prior to seeing your child. Please check the box below. *
Please email amywork@renwedcounseling.net if you have any questions/concerns about this policy.
Required
Is there anything else you would like us to know?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Renewed Counseling & Play Therapy. Report Abuse
Google Forms