Counseling Request Form

Is the client under the age of 18?(required)

Yes No

Client’s First Name

Client’s Last Name

Client’s Date of Birth (MM/DD/YYYY)

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

Preferred Language

English Spanish

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 number

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 First Name

Parent/Caregiver Last Name

Relationship to Youth

Physical Address

Parent/Caregiver First Name

Parent/Caregiver Last Name

Relationship to Youth

Phone Number

Email

Referral First Name

Referral Last Name

Organization

Phone Number

Email

Requesting Counseling

Referral Form

Thank you for your response. ✨