Step Up — Zebra Health + Digital

New Client Registration

Zebra Health+Digital is providing accessible online mental health counseling for students and families!

We are ready to assist.

We are proud to have partnered with numerous school districts, achieving remarkable results in enhancing students’ mental health and well-being. Our proven track record of success demonstrates our commitment and effectiveness in supporting children. These positive outcomes inspire us to maintain the highest standards in mental health telehealth services. Trust us to provide your child with the professional care they deserve, ensuring they thrive both emotionally and academically.

Our therapists are here to support you!

We have a team of amazing therapists and specialists to help you achieve your goals through a variety of customizable services.

Client's full name

First Name

Last Name

Client's Date of Birth

MM

DD

YYYY

Client's gender

Client's grade level

Client's school/district name

Client's email address

Name of Legal Guardian

First Name

Last Name

Relationship to Client

Guardian's phone number

(###)

###

####

Alternate phone number (work or cell)

(###)

###

####

Guardian's email address

Secondary Contact for Client if above Guardian is not available

First Name

Last Name

Secondary contact's phone number

(###)

###

####

Client's preferred day and time for sessions

Please indicate the best availabilities and we will do our best to accommodate

Zebra's telehealth services you are interested in (check all that applies).

Student individual therapy

Family therapy (parent + student)

Diagnostic Screening

ADHD Screening

Psycho-educational Evaluation (Learning Disability)

Additional information

Reason for visit, general concerns you would like to share, language preference, or any information we should know that will help with the sessions, etc.

New Client Registration

Zebra Health+Digital is providing accessible online mental health counseling for students and families!

We are ready to assist.

Our therapists are here to support you!

Thank you! We will be in touch to schedule a time with you.

If you have any questions or comments, please feel free to contact us at any time.

Zebra Health + Digital

hello@zebrahd.com