Mindful Child & Family Therapy
Appointment Request

Welcome! We’re so glad you are reaching out for support, and we look forward to getting to know you. Please fill out our form and we’ll help you get set up with the therapist who will best fit your needs.

Name *

Email *

Phone *

How do you prefer to be contacted?

If you selected "phone", or if your email bounces back to us, may we leave a message on the above phone number?

Whom are you seeking counseling for?

If seeking support for a minor, indicate your current parent or guardian relationship status:

Would you like to:

Your Preferred Location: *

Times you are looking for:

Please Provide 3 Times You Are Available for Counseling

Are you hoping to work with a particular therapist? If so, please select:

Please let us know any preferences you have around the therapist's gender, race, culture, language or LGBTQ+ affiliation:

Please let us know why you are seeking support:

Please list your insurance (MCAFT is considered an out-of-network provider):

Please check all insurance that you carry or plan to carry:

How important is it to you to be able to use your insurance?

How did you hear about MCAFT?

Would you like to receive information about retreats / workshops / classes and/or free Parent Ed Nights sent to your email?

Email and SMS Text Message Risk Acknowledgement and Use Consent

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Mindful Child & Family Therapy therapists, providers, and/or office staff communicating with me via email or text message