Individual Services with Dandelion Family Counseling

Dandelion Family Counseling

newclient@dandelionfamilycounseling.com

Who are you seeking services for?

Myself / Adult

Child / Children

Both

Your first and last name

What is your child's first and last name?

How old is your child?

Please note we only provide services for children ages 4-13

What is your email?

What is your phone number?

What state do you live in?

How did you hear about Dandelion Family Counseling?

I acknowledge that Dandelion Family Counseling is a self-pay practice and DOES NOT ACCEPT INSURANCE. Full payment will be due at time of service. A super bill can be provided for potential out-of-network reimbursement.

What diagnoses (confirmed or suspected) or concerns are you hoping to address in counseling for your child? Check all that apply or are suspected. *Please note that we specialize in ADHD and Autism, so our techniques work best with children who have traits that align with those diagnoses.

ADHD / ADD

Anger / Frustrations

Anger / Outbursts

Anxiety

Autism / Aspergers / Social Pragmatic Communication Disorder

Gifted

Pathological Demand Avoidance

Michelle is our only PDA specialist

Sensory Processing Disorder (SPD)

Social Skills

Our groups are only offered at our Southpark location

What diagnoses (confirmed or suspected) or concerns are you hoping to address in counseling for yourself? Check all that apply or are suspected. *Please note that we specialize in ADHD and Autism, so our techniques work best with children who have traits that align with those diagnoses.

ADHD / ADD

Anger / Frustrations

Anxiety

Autism / Aspergers / Social Pragmatic Communication Disorder

Depression

Executive Functioning support

Parenting Support

Pathological Demand Avoidance

Michelle is our only PDA specialist

What child-based services are you interested in? Please check all that apply

Individual Counseling- Play Therapy/Play Based Counseling AND Parent Coaching

Weekly parent sessions are a required part of this process (Most families need a minimum of 8-12 parenting sessions)

Social Skills Group (Ages 4-12)

Only offered at our Southpark location

Anxiety Skills Group (Ages 9-12)

Only offered at our Southpark location

Parenting Support Only (no child sessions with this service)

Only available with Michelle, Alyse & Geoff

What services for adults are you interested in? Please check all that apply

Individual Counseling- Adult Counseling

Virtual or in person available

Parenting Support Only (no child sessions with this service)

Only available with Michelle, Alyse & Geoff

Is there a divorce, separation, custody agreement or co-parenting arrangement? If yes, both parents will need to submit our paperwork prior to the parent intake

Yes

I acknowledge that if there is a separation, divorce, custody agreement or co-parenting arrangement, both parents are required to complete paperwork prior to the parent intake in order for my child to work with therapists at Dandelion Family Counseling.

I acknowledge that Dandelion Family Counseling specializes in intensive parenting support. Parent sessions are a required part of individual counseling and focus on parenting strategies specific to your child's diagnosis and personality. These are a separate charge from your child's individual session.

Weekly parent sessions for a minimum of 8-12 weeks are required for most families.

For adults we have two locations, which location is most ideal for you?

Southpark

(Michelle & Alyse)

Huntersville

(Michelle, Alyse & Geoff)

Either Southpark or Huntersville

Virtual

(only available for adults- Michelle, Alyse & Geoff)

For children we have two locations, which location is most ideal for you? Please note that only Alyse, Michelle, Louisa & Geoff are available at our Huntersville location.

Southpark

Huntersville

Either Southpark or Huntersville

Virtual

(only available for adults)

Which 2 therapists do you think would be a good fit for your family? (Please refer to therapist listing on our website)

Please note, Michelle is our only PDA specialist.

Thank you for your interest in our services. Due to the large number of new client inquiries, the following steps are a necessary part of our process.
1) Shortly after your online form is received, you will be sent an email from our Administrative Intake Assistant notifying you that we have received your request and that the next required step is completing paperwork through IntakeQ.

2) Complete IntakeQ paperwork. This is information regarding our policies and procedures and includes a detailed questionnaire so we learn more about your child and whether or not we are a potential right fit. This is a required step. Please note, if you do not complete this step within 7 days, you will no longer have access to the IntakeQ paperwork and will need to submit another online form to restart the process.

3) Once paperwork has been reviewed, our Administrative Intake Assistant will contact you by email to inform you whether or not we may be a fit for your family. At that time a phone call will be offered to discuss next steps and answer any questions about our services.

Your information will be encrypted.