Join Our Waitlist

Join Our Waitlist for Child & Adolescent Therapy

All of our child and adolescent therapists are currently at full capacity. If you’d like to be notified when an opening becomes available, please complete the waitlist form below. We’ll reach out directly as soon as we’re able to offer a consultation.

"*" indicates required fields

PART 1: Contact Information

Name of Contact Person (Usually the Person Completing This Form)*

Contact Person's Relationship to Client*

Please describe your relationship to the client:*

Contact Phone (U.S.)

Contact Phone (International)

Please list any restrictions for information communicated via phone and/or voicemail:

May our office call and/or leave a message at this number?*

Contact Email*

Enter Email Confirm Email

May our office email you at this address with information related to services and/or scheduling an appointment?*

Please list any restrictions for information communicated via email:

PART 2: Referral Information

Were you referred by someone?*

Yes

Who referred you?*

How did you hear about Curry Psychology Group?*

PART 3: About the Client

Name of Child or Teen ("the Client")*

Client's Age*

Current City/State of Residence:*

Is the Client Covered by Tricare Military Insurance?*

Yes, the client is a Tricare beneficiary

No, we will be paying for the client's service out-of-pocket

Name

This field is for validation purposes and should be left unchanged.

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