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Request counseling

NEW CLIENT INFORMATION

Do you/your child have health insurance?

CONTACT INFORMATION FOR SCHEDULING

COUNSELING REQUESTED

Select all that apply.
Reason for Counseling:
Are you/your child currently receiving mental health care?

CAREGIVER INFORMATION 

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 call 830-629-6571.

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