Initial Consultation Request

Our team is here to help you with any questions or needs you have. If you would like to speak with one of our clinicians, please feel free to either call, email, or complete the form below, and our team will be happy to answer any questions you have, and schedule a free consultation.

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*

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

Tuesday*

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

Wednesday*

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

Thursday*

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

Friday*

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

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

Comments

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

047777 8414

General Information

Daily Availability for Services

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