Request appointment | Kenneth Small PhD & Associates/Thrive Counseling, Consulting, Training and Wellness, LLC

Any history of violence?

Any active PFA, SVP, or PFI?

If Yes, select which:

If Yes, please provide a copy of Order prior to session.

PFA SVP PFI

On Probation or Parole?

Yes No

If Yes, Probation Officer Name:

If Yes, Probation Officer Contact Phone:

Any on-going legal issues?

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.