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New Client Request

Find Your Avenue for Change

Fill out this form and we'll be in touch as soon as possible.

The client is a minor (under 18)

Check this box if you are a parent or guardian requesting therapy for a child.

As the parent or guardian, your contact information will be used for all communication. Please provide the child's name and age below.

Parent / Guardian First Name *

Parent / Guardian Last Name *

Child's First Name *

Child's Last Name *

Child's Age *

About You

First Name *

Last Name *

Email Address *

Phone Number *

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Client Age *

Pronouns (optional)

Therapist & Service

Preferred Therapist *

No Preference Eric W. Baker, Jr. Lauren E. Grammer Laura A. Purcell Teah Williams-Hampton Phoenix Fowler Melissa R. Jobe Isabelle Rastler-Cross Megan Roberson

Type of Service *

Your Availability

Days Available *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred Times

No Preference Mornings (8AM–12PM) Afternoons (12PM–4PM) Evenings (4PM–7PM)

About Your Goals

What would you like to work on in therapy? *

How did you hear about us? (optional)

Anything else we should know?

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If you are having an emergency, please go to your nearest emergency room,
dial 911, or call the crisis line at 1.800.273.8255.

Questions? Call us at 502.459.9635 or email office@avenuesunlimited.com.

1774 Mellwood Ave., Louisville, KY 40206

502.459.9635

info@avenuesunlimited.com

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