Counseling Referral | Connections

Counseling Request Form

Request counseling

NEW CLIENT INFORMATION

Youth's First Name

Youth's Last Name

Date of Birth required

Current School (Use N/A if not applicable)

Other

CAREGIVER INFORMATION

Caregiver's First Name

Caregiver's Last Name

Relationship to Youth

Primary Phone

Secondary Phone

Email

Street Address

City

Region/State/Province

Postal / Zip code

Do you/your child have health insurance?

Yes

No

Unsure

Please provide your insurance provider

Preferred Language

English

Spanish

Other

Language

ADDITIONAL CAREGIVER INFORMATION (optional)

First Name

Last Name

Relationship to Youth

Phone

Email

TYPE OF COUNSELING REQUESTED

Other Notes

Are you/your child currently receiving mental health care?

Yes

No

Please share provider details:

Have you previously received counseling services through Connections?

Yes

No

Unsure

REFERRAL INFORMATION (if applicable)

First Name

Last Name

Organization

Phone

Email

Please contact me for additional information prior to contacting client(s)

Thank you for your submission! A counselor will be in touch with you soon; please be patient as many of our staff have reduced summer availability as they gear up for the school year.
If you haven't been contacted in one week, please contact Program Director Kristin Ray at 830-629-6571 x230 or kray@connectionsifs.org.

Counseling Request Form

New Client Information

Request counseling

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