Counseling Session Request Form
Request for 6 free Clinical Counseling sessions which are led by a Clinical Mental Health Intern or Registered Marriage and Family Therapist. We do not diagnose or evaluate. 

Requests on behalf of someone else are not permitted unless it is a legal guardian requesting for a minor.
If a client is 18 or older, they must request for counseling themselves.

For Minors, please enter their first and last name below, but the guardian's phone and email.

We only offer IN-PERSON appointments. 
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Phone Number of Self or Parental Guardian *
Email Address of Self or Parental Guardian *
Which form of Counseling would you like? *
Do you need a Spanish Speaking Counselor? *
Please check off your availability. (Appointments are scheduled weekly at the same time.) *
Required
Please give a brief summary as to why you are wanting counseling.  (Required) *
Please select one: *
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