Brave Young Minds | SimplePractice

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I am at least 18 years old

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e.g., male (him/his), female (she/her), nonbinary (they/them), trans male (he/him), etc.

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PARENT 1 first name

PARENT 1 last name

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PARENT 2 first name

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.

Who would be receiving care?

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