Rachel GladysTherapeutic Services

cultivating healing, growth, and change, through connection & the magic of play.

Your First Name

Phone Number

Name of Potential Client

Your Last Name

E-Mail Address

Age of Potential Client

I am the potential client's *

Parent

Legal Guardian

I am the potential new client.

Which of the following best decribes your relaionship with the potential client's second parent?

We are currently married.

We are in a relationship, but we are not married.

We are engaged.

We are currently divorced.

We are currently seperated and pursuing a divorce.

We do not have a relationship.

Can you provide a copy of the signd court order granting you legal guardianhip of the child?

Yes

I don't know.

Can you provide a signed copy of the active parenting plan or temporary order pertaining to custody?

Yes

I don't know.

Mark the boxes indicating when you are available for the consult call. * Required

Tomorrow (or the next business day) between 9:30a-12:00p

Tomorrow (or the next business day) between 12:15p-1:15p

Tomorrow (or the next business day) between 1:30p-4:30p

Tomorrow (or the next business day) between 4:45p-7:45p

Two business days from today, between 9:30a-12:00p

Two business days from today, between 12:15p-1:15p

Two business days from today, between 1:30p-4:30p

Two business days from today, between 4:45p-7:45p

Three business days from today, between 9:30a-12:00p

Three business days from today, between 12:15p-1:15p

Three business days from today, between 1:30p-4:30p

Four business days from today between 4:45p-7:45p

Is there anything else you'd like me to know before we speak?

Thanks for submitting!

Within 24 hours, I will contact you via e-mail to confirm a time for the consult call based

on the availability you shared in the form. If you have any questions in the meantime,

please contact me via e-mail.

Rachel Gladys Therapeutic Services

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