Please complete the information in each of the four sections below and submit the form.

Client Information

(if client is younger than 18)
Please select all that apply


YFC will check your benefits.

Reasons for Seeking Therapy

This will help us select the right therapist for you.

Appointment Preferences

While selecting the days of the week and time frames that you are available for weekly, consistent appointments in the below chart, please note that YFC cannot guarantee your appointment preferences will be available.