ABC's of Building Better Lives, LLC

Demographics

Step 1 of 5 1 of 5 steps

Your info

First name

Last name

Phone

Date of birth

Gender

Address

Provide street number, street name, city, state, and zip code

Parent/Guardian Name

Please complete if client is a minor (under 18 years of age). Otherwise, type N/A.

Parent/Guardian Email Address

Type N/A if client is 18 years of age or older. For minor clients under 14 years of age, parent/guardian email is required, as parent/guardian will need to sign intake packet. If client is 14 to 17 years of age, provide the 14-17 year old's email address so they can sign the intake packet. Parent/Guardian and Client cannot use the same email address.

If client is under 18 years of age, is there an active custody agreement?

Select "No" for client 18 or older. If yes (for clients under 18 years of age), custody agreement must be provided at intake appointment

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.