New Client

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 *

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?

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

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 [email protected].

1774 Mellwood Ave., Louisville, KY 40206

502.459.9635

info@avenuesunlimited.com

Facebook Twitter Instagram Envelope

Schedule an Appointment

About
Services
Forms

About
Services
Forms

Resources
Contact
Home
Join Our Team

Resources
Contact
Home
Join Our Team

Terms & Conditions | Privacy Policy | No Surprise Act

Design by Perennial Creative Co.

This site uses cookies to provide you with a greater user experience. By using AvenuesUnlimited.com you accept our use of cookies.