To initiate service, please complete the following form. A representative will call within one business day to confirm the request. If you are able to come into our office, an appointment will be scheduled at that time. If you are in need of home or school based service and are enrolled in the Medicaid program, a counselor will call to schedule the appointment within three business days.

Your answers to the following questions are kept in the strictest confidence and will be used to assign a counselor with experience in working with your specific needs.

I am

Issues to be Addressed:

Issues to be Addressed:

Depression Sexual Abuse
Behavior Problems Communication Problems
Abuse/Neglect Oppositional Defiant Disorder
Family Conflict Divorce Adjustment Issues
Anger Management Substance Abuse
ADD/ADHD Loss and Grief
Poor Self-Esteem Stress Management
School Problems Adjustment Disorder
Anxiety
Other (please describe):

Client Data:

*Name:

*Address:

*City:

*State:

*Date Of Birth:

*Zip Code:

*Phone:

*Email:

Parent Name :

Referral Source (if different than above)

Name:

Agency/School:

Phone:Fax:

Email:

Method of Payment:

Medicaid #