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Services
About
Get Started
Take the First Step
Once this form is completed, our experienced team will connect with you at your chosen time to complete intake and embark on your healing journey together.
Guardian Primary Language
English
Spanish
Other
Client Primary Language
English
Spanish
Other
Service Requested
Individual Therapy
Group Therapy
Play Therapy
Family Therapy
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Mentoring with a Qualified Health Professional (Case Management)
Addiction Counseling
Medication Management
Trauma Treatment
ADHD Testing
Behavioral Assessment
I'm Not Sure
I prefer to be seen by
Male
Female
Do you require a bilingual staff member to provide services/assist you?
Yes
No
I prefer to have the session
Virtual
In-Person
No Preference
Guardian/Client's Email
Client's First Name
Client's Last Name
Client's Date of Birth
Client's Phone
Client's Address
City of Residence
Select
Houston
San Marcos
San Antonio
Austin
Dallas
Other
Main Insurance Provider
Secondary Insurance Provider
Do you have Medicaid
Yes
No
Do you have Medicare
Yes
No
Insurance #
Add any other family members
I was referred by
Select
School
Person
Elite Vision
Facility
EMC Staff
Other
Name of person/school/facility that referred you
Calling Preference
Morning
Noon
Evening
I do understand this form is only a referral to receive services from EDUVENTION and it does not guarantee enrollment into the program.
I accept these terms
Requested appointment time
Submit
