Service Requester (Please remember that all of your information is confidential unless you request that we release information or in the event that you are a threat to yourself or someone else)
Please tell us a little more about yourself
Recent Experience
Provider (Mental Health Professional) Preferences
Who will be attending counseling in addition to you? Please note that you are not permitted to request individual counseling services for another adult. Individuals 18 and over MUST request their own services. Indivudals 18 and over can be included in couples or family requests.
We may match you with a third-party provider. We are not responsible for the data use practices of third-party providers. By pressing the “Submit” button, you consent to us sharing your personal information with a third-party provider.