Counselors At Home
Please fill out this form to request a Counselors at Home booking or let us know more about your family's needs.

In order to complete a booking you will need the dates and times you'll need care, contact information for all parents/guardians as well as additional emergency contacts, names and ages of all children, location details (address, house rules, pets, parking etc), as well as health and safety information for all attendees.  

If you're interested but need to partner with another family, we may also be able to introduce you to others who are looking to form a Pod.

If you just need more information before you can commit, we can help with that too.

After you submit this form, our local team will be in touch within one business day. Thanks!
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Parent / Guardian First and Last Name *
Parent / Guardian Email Address *
Parent / Guardian Phone Number *
Preferred Contact Method - Please ensure you've provided correct information for your preferred method *
Required
Where do you live? *
This allows us to know how we can best partner with you based on Counselor's service areas
How can we help you? *
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