Accepting new patientsTexas residents onlyWe do not accept MedicaidNow open: North Dallas office
Online patient form

Minor Therapy Pre-Screening Form

Fields marked * are required. Your answers are sent securely to our intake team — nothing is stored in your browser.

Before scheduling therapy for a minor, the following questions must be completed.

1. Parent / Guardian Relationship Status

What is the relationship status of the child’s parents?

2. Legal Custody Status

Who currently has legal custody of the child?
If unsure, custody documentation will be required before scheduling.

3. Court Involvement

Are there any current or anticipated legal proceedings involving custody or parenting?
Examples include:
  • custody litigation
  • custody modification
  • family court hearings
  • mediation related to custody
  • guardian ad litem involvement

    • If Yes, our clinic may not be able to provide services and may offer referrals to court-involved specialists.

    4. Parent Awareness of Therapy

    Are all legal guardians aware of the request for therapy?

    5. Parent Support for Therapy

    Do all legal guardians support the child attending therapy?
    If guardians disagree about treatment, therapy cannot begin until agreement is reached.

    6. Legal Documentation Expectations

    Is any parent requesting that the therapist provide letters, documentation, or testimony for legal proceedings?
    If yes, families will be referred to clinicians specializing in forensic or court-involved services.

    7. Certification of No Custody Litigation


    Applicants must certify:

    I confirm that there are no active custody disputes, legal proceedings, or anticipated court actions involving the child that would involve the therapist or therapy records.

    Your submission is emailed securely to our intake team. This form is not for emergencies.

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