Parent/s - Submission Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

Country

(###)

###

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Participating Child'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 parent (by birth, adoption, fostering, … ) seeking support with...

Relationship with my child.

Being overwhelmed with parenting.

Attachment and communication.

Navigating affirming my child’s autonomy while disciplining them.

Understanding, accepting, and/or affirming my/my child's gender identity and/or sexual orientation.

Taking accountability for the harm I caused/might have caused to my child.

Reconciliation with my child.

My child’s trauma/destress (Children ages 3-17).

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.