Intake Form Δ Full Name*Email* Court Use OnlyCase NumberCourt/CountryJudge / Hearing Officer:SignatureDate MM slash DD slash YYYY Requested Services (Check All That Apply)Trauma & Reunification Individual Trauma Therapy Family Therapy Reunification Therapy Court-Involved Family Stabilization Reunification Readiness Support Domestic & Relational Domestic Violence Counseling Victim Support Services Batterer Intervention (Trauma-Informed) Domestic Violence Counseling Parenting & Co-Parenting Parenting Education Trauma-Informed Parenting Therapy Co-Parenting Counseling Cooperative Parenting Therapy High-Conflict Co-Parenting Support Child & Attachment Parent-Child Relationship Therapy Attachment Repair Therapy Child & Family Emotional Regulation Support Substance-Related Services Substance Abuse Aftercare Therapy Relapse Prevention Therapy IOP Aftercare Support Services Family Support for Substance Recovery This field is hidden when viewing the formConsent* By checking this box, I agree to receive recurring promotional and personalized marketing text messages (e.g., cart reminders) from Wings of the Future at the mobile number provided. Consent is not a condition of purchase. Message & data rates may apply. Message frequency varies. Reply HELP for help and STOP to cancel. By clicking 'submit' you agree to our Terms & Conditions and Privacy Policy.*
