Counseling Request Form

Please fill out the form below with the information of the individual seeking counseling.

After the form is submitted, a counselor will be in touch with you in 5-7 business days.

Is the client under the age of 18?

Yes
No

Name

First

Last

Client's Date of Birth (MM/DD/YYYY)

Client’s School (use N/A if not in school)

Client's County of Residence

Client's Address

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Languge

English
Spanish
Other

Please provide an email address and phone number for the counselor to contact you.

If the client is a child, please provide an email address and phone number for the primary parent/caregiver.

Email

Phone

Primary Contact

The person identified in this section will be the primary contact for minor clients (17 years old and younger).

If you are an adult seeking counseling services, you can skip this section.

Parent/Caregiver Name

First

Last

Relationship to Youth

Secondary Contact

If you would like to list a secondary contact for minor clients (17 years old and younger), please fill out this section.

If you are an adult seeking counseling services, you can skip this section.

Parent/Caregiver Name

First

Last

Layout County Counseling

Relationship to Youth

Email

Phone

Additional Information

Is the person seeking counseling services receiving mental health care?

Yes
No

Has the person needing counseling services previously received counseling services through Connections?

Yes
No

Does the person seeking counseling services have healthcare?

Yes
No
Unsure

Referrer Information

If you are referring a client on behalf of another organization, please fill out this section.

Referrer Name

First

Last

Referring Organization

Email

Phone

Contact

Please contact me before reaching out to the client.

Requesting Counseling