Request an Appointment

Client's Name *

If this appointment is for a child, input child's information.

First Name

Last Name

Date of Birth *

If this appointment is for a child, input the child's information.

MM

DD

YYYY

If this appointment is for a child, input parent's full name.

First Name

Last Name

Phone Number *

(###)

###

####

I am interested in the following service(s): *

check all that apply

Therapy

ADHD & Autism Evaluation (A $500 deposit is deposit is required when scheduling the initial intake appointment)

Executive Function, Sensory Processing & Interoceptive Awareness Assessment (A $500 deposit is deposit is required when scheduling the initial intake appointment)

I acknowledge the following: *

True Reflections Mental Health Services DOES NOT ACCEPT INSURANCE and is an OUT OF NETWORK PROVIDER. The full fee is due at the time of the appointment and a statement of reimbursement is provided to those submitting to their insurance for out of network benefits. For information on fees, please visit: https://www.truereflectionsmhs.com/fees-out-of-network

True Reflections Mental Health Services sees clients on Tuesdays, Wednesdays, and Thursdays 10:00am-4:00pm. Upon request, I am able to provide a letter excusing you from work or your child from school due to having to attend your clinical appointment.

If this appointment is for a child, written consent is required from both parents if parents are separated/divorced. Written signed consent must be provided electronically in order to be able to request an appointment. Be advised, that I do not participate in any court related matter and do not offer an opinion or recommendation, especially as it relates to custody.