This form is confidential but not intended for emergency use. Please don’t include sensitive or urgent information. If this is an emergency, call 911 or your local emergency services.

Client Information

Full name*

Please enter the client’s full name.

Preferred name (optional)

Date of birth

Age

Pronouns (optional)

Contact Information

Email address*

Please enter a valid email address.

Phone number*

Please enter a phone number.

Preferred method of contact

${CHECK}Email ${CHECK}Phone ${CHECK}Text

Who is this inquiry for?

${DOT}Self ${DOT}Child ${DOT}Teen ${DOT}Adult

Please choose who this inquiry is for.

For a child or teen:

Parent / guardian name

Relationship to child

Services You’re Interested In

Check all that apply.

${CHECK}Comprehensive Psychological Evaluation ${CHECK}Consultation / Second Opinion ${CHECK}Therapy Services

Primary Concerns

Briefly describe the concerns that led you to reach out (e.g., attention, learning, anxiety, behavior, emotional concerns, school difficulties). A general description is all we need here.

Please keep this general. Don’t include private health details — diagnoses, medications, or sensitive history. This form isn’t a secure place for that; we’ll gather anything clinical safely once we connect.

Assessment / Therapy Preferences

Preferred format

${DOT}In-person ${DOT}Virtual ${DOT}Open to either

Insurance & Payment

${CHECK_DARK} I understand that services are private pay and insurance is not accepted at this time. A superbill can be provided to submit to insurance for possible out-of-network reimbursement, which is not guaranteed.*

Please acknowledge to continue.

Would you like information about payment plans (if available)?

${DOT}Yes ${DOT}No

Availability

Best days / times for appointments

How did you hear about us?

${CHECK}Psychology Today ${CHECK}TherapyDen ${CHECK}School referral

School name

${CHECK}Physician / Provider referral

Provider name

${CHECK}Internet search ${CHECK}Friend / Family

Friend / family name

${CHECK}Other

Tell us more

Consent to Contact

Fields marked * are required. We typically respond within 1–2 business days.

Your inquiry is on its way

Thank you for reaching out to LexiRose Psychological Services. We’ve received your inquiry and will be in touch within 1–2 business days to talk through next steps.

If you need to reach us sooner, call 916-304-4995.