Initial Consultation Request

Ready to schedule your free consultation with one of our clinicians? Our team is available from 8:30am-5:30pm CST to answer any questions you have, and to schedule your free consultation. Give us a call today!

If it is outside of business hours, or if you prefer to submit your request online, please complete the form below and our team will contact you to complete your request. We look forward to speaking with you!

General Information

Parent/Guardian First Name*

Parent/Guardian Last Name*

State/Province/Region*

Nearest Region*

Zip Code / Postal Code*

Phone Number (US and Canada)*

Phone Number (Australia)*

Email*

Insurance Type*

Child's Age Range*

Daily Availability for Services

Monday*

Monday

All Day
8am-Noon
Noon-3pm
3pm-7pm
Not Available

Tuesday*

Tuesday

All Day
8am-Noon
Noon-3pm
3pm-7pm
Not Available

Wednesday*

Wednesday

All Day
8am-Noon
Noon-3pm
3pm-7pm
Not Available

Thursday*

Thursday

All Day
8am-Noon
Noon-3pm
3pm-7pm
Not Available

Friday*

Friday

All Day
8am-Noon
Noon-3pm
3pm-7pm
Not Available

Saturday*

Saturday

All Day
8am-Noon
Noon-5pm
Not Available

Additional Availability Information

How did you hear about EAS?*

How did you hear about EAS? (Other)

Initial Intake ID

Email

This field is for validation purposes and should be left unchanged.

047777 8414

General Information

Daily Availability for Services

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