Name *

First Name

Last Name

Phone *

(###)

###

####

Parent/Guardian Name (if under 18) *

First Name

Last Name

I understand that parental participation in the initial phone consultation and intake is required for all minors (under the age of 18). I understand that parents will be provided with periodic updates on child's engagement throughout therapy. *

Yes

No

Are you located in North Carolina or Virginia? *

Yes

No

Renewed Resilience is an online practice. Are you okay with receiving therapy via HIPPA compliant video service? *

Yes

No

Please Select Your Availability *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Evenings Only