Once the form is completed you will be contacted so we can obtain additional
information and schedule your first session. 

Name *
Name
Address *
Address
Phone Number
Phone Number
 

Parents EMPOWERMENT program  |  Full Price: $250 or 2 payments of: $125

Registration is not final until payment is made.  (We accept Debit, MasterCard, Visa and AMEX).

Parents Name *
Parents Name
Address *
Address
Phone Number
Phone Number
Childs Name *
Childs Name
Childs date of birth *
Childs date of birth

Registration is not final until payment is made.  (We accept Debit, MasterCard, Visa and AMEX).

Once completed you will be contacted to schedule your visit. 

Clients Name *
Clients Name
Parent/Guardian
Parent/Guardian
Date of Birth *
Date of Birth
Phone Number *
Phone Number
Client's Name *
Client's Name
Client's Date of Birth *
Client's Date of Birth
Parent/Guardian's Name *
Parent/Guardian's Name
Phone Number *
Phone Number
Date of Discharge (if applicable)
Date of Discharge (if applicable)
Referring Person *
Referring Person
Phone Number *
Phone Number