Intake form

Name *

Email address *

Child's age

What are the main concerns you would like to address?

Please select at least one option.

ADHD

Anxiety

Depression

Behavioral Issues

Social Skills

Academic Performance

Has your child received any previous psychological support?

If yes, please specify the type of support received

Do you have any specific goals for the therapy?

Preferred appointment days

Please select at least one option.

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred appointment times

Please select at least one option.

Morning

Afternoon

Evening

Any relevant medical history?

How did you hear about thriving mind studio?

Which service or services are you interested in?

Please select at least one option.

Individual therapy for children

Teen counseling

ADHD support programs

Additional questions or comments

Thriving Mind Studio