PATIENT INFORMATION Patient's Name * First Name Last Name Parent/Guardian Names (if patient is under 18): First Name Last Name Email * Phone * (###) ### #### Age of Patient: Patient Identifies as: He/him She/her They/them Other Details What services are you interested in? Individual therapy Family therapy Parent coaching SPACE Treatment Child and parent therapy Substance use screening Resilience Builder Program What therapist are you interested in working with? Dr. Jeremy Salzman Jess Hathorn, LPC Dr. Steedy Kontos Grace Brown, AMFT Not sure How do you want to work? In-person Virtually Hybrid What prompted you to see our services, and is there anything else you would like us to know? Referred by: Thank you! We will be in touch soon to schedule your complimentry consultation. Book A Consultation Visit1801 Peachtree St. NE, Suite 160Atlanta, GA. 30309 Call404-549-3994Writeinfo@intownpsych.com Follow Virtual Sessions Available BOOK A CONSULTATION
