Child - Submission Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

Country

(###)

###

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Participating Parent's Name *

First Name

Last Name

Participating Co-Parent's Name

(If applicable)

First Name

Last Name

Participating Co-Parent's Name

(If applicable)

First Name

Last Name

I'm reaching out for consultation.

15 minutes free phone consultation.

I am a child (by birth, adoption, fostering, … ) seeking support with...

Relationship with my parent/s.

Attachment and communication.

Conflict resolution.

Navigating childhood scars (emotional/physical).

Understanding, accepting, and/or affirming gender identity and/or sexual orientation.

Accountability and reparation for the harm my parent/s caused/might have caused growing up.

Reconciliation with my parents.

Not listed above, please read my message below.

Privacy and Security *

I understand that communications via email over the internet are not secure. Although unlikely, I understand that there is a possibility that an unintended party could intercept and read the contents of an email. I also give Just Healing Psychotherapy permission to leave a message at the phone number and email address provided.