Brief Screening FormProviding some background information will help guide your free call with Dr. Zia. Please take a few moments to complete the form below before scheduling your call.*Please indicate the type of care: I'm looking for Caregiver Support I'm looking for Individual Therapy for my child I'm looking for Group Therapy for my child I’m looking for Caregiver Group Therapy I'm looking to help my child but unsure of what I need I would like to BOOK a workshop or training session with Dr. ZiaName of Person Completing This Form:(Required) First Last Name of the child you are seeking help for:(Required)Client Age:(Required)Your Preferred Email Address(Required) Your Phone(Required)Referral Source:(Required)Please briefly describe your presenting concerns(Required) Before submitting this form please review the following: Is it often a recommendation that caregivers participate in a group intervention prior to beginning caregiver therapy or individual therapy with a child. Research strongly supports the role of caregivers in child regulation, and this is viewed as an essential foundational component at the outset of treatment. Recommendations will be made after a brief screening call, which will include details on fees associated with treatments and programming suggested. At FFEW we do not offer the following services: psychological assessment; treatment for eating disorders; neuropsychology; treatments for children diagnosed with Autism. If for any reason Dr. Zia feels unable to support you and your goals, alternative referrals will be provided. I have read the above terms:(Required) Yes, I AgreeBOOK a workshop or training session with Dr. ZiaWhat type of service are you looking for (check all that apply):(Required) Professional Workshop Training Speaking Engagement Group Consultation OtherName of Person Completing This Form:(Required) First Last Preferred Email Address:(Required) PhoneReferral Source:(Required)Please briefly describe what you are looking for:(Required)Please double check your email and phone number above.(Required) Yes, I have checked.IMPORTANT: This is Step 1 of 2. After submitting your form, please wait for the next page to load to schedule your screening call.
