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Breakthrough Counseling, LLC Applicant/Referral
If you are completing this form for someone other than yourself or your child, please do not do so without their consent. Breakthrough Counseling does their best to reach out to all referrals within 48 business hours.
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Who referred you?
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Self (Potential Client or Parent/Guardian)
School Employee
Church Employee/Member
Community Agency Employee
Other
Referred Individual's (Potential Client) Name
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Your answer
If youth client, please place parent/guardian's name:
Your answer
Potential Client's email Address?
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Your answer
What is client's age?
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Your answer
What is the best phone number to reach Client? if youth what is the parent's phone number?
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Your answer
Reason for Counseling (examples include, Anger, Depression, family conflict, communication, parenting...)
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Your answer
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