Ready for your Breakthrough?

Thank you for your interest in "Children, Adolescent, and Young Adult Services" at Breakthrough Coaching Center. Our specialists are committed to a family-centered care approach to promote positive emotional, behavioral, psychosocial, and professional development. Whether your family is navigating a medical diagnosis, in need of new coping strategies, or seeking ways to better prepare your child for the world, we are here for you! Our main goal is to instill resiliency in our youth and families, allowing them to thrive despite challenges, adversity, trauma, or life changes.

Please complete the form below if you are interested in a complimentary 30-45 minute consultation with our Specialists.

**If you are seeking support services for more than one child, please complete an individual form for each sibling.

Name: Primary Caregiver

First Name

Last Name

Name: Potential Client

First Name

Last Name

Potential Client DOB

YYYY

Caregiver Email Address (if under 18)

Potential Client Email (if over 18)

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If you are completing this form on behalf of a potential client/child, please share your name, best form of contact, and relationship to child.

Please briefly share your reason for pursing therapeutic services.

Is there a medical diagnosis? If so, please include diagnosis and current medication.

How did you learn about us?