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Request counseling

NEW CLIENT INFORMATION

CAREGIVER INFORMATION 

Do you/your child have health insurance?
Preferred Language

ADDITIONAL CAREGIVER INFORMATION (optional)

TYPE OF COUNSELING REQUESTED

Select all that apply. Required
Reason for Counseling (Select all that apply):
Are you/your child currently receiving mental health care?
Have you previously received counseling services through Connections?

REFERRAL INFORMATION (if applicable)

Thank you for your submission! A counselor will be in touch with you soon.
If you haven't been contacted in one week, please contact Program Director Kristin Ray at 830-629-6571 x230 or kray@connectionsifs.org.

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