Private Sessions Intake Form

Please fill out this intake form as soon as possible so that Marydee has time to review it prior to your first session. Thank you!

  • Please provide the full name of each participant, their preferred pronouns, and their relationship to the primary participant. Remember, if the primary client is a student, a least one parent or adult support figure MUST attend the sessions as well.
  • General Intake Information

  • ADD/ADHD, Dyslexia, Learning Differences, Gifted and Talented, Processing Disorders, Premature Birth, Adopted, Mental Health Diagnosis
  • Please let us know how you heard of us.
  • Additional Questions for Students and Families

    Please fill out this section if the primary participant is a student.
    I understand that the course duration includes 10 1-hour sessions, paid in advance. If I desire or need additional 1-hour sessions beyond the 10-session package, I'll be charged for the individual session and must pay in advance of the session.
    I understand that there is a 72-hour cancellation policy for private sessions. I understand that if I cancel within the 72-hour window, I will need to purchase an additional session to make it up.
    We respect your privacy and will never share your email address.
Skip to content