Counseling Referral | Connections

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Request counseling

NEW CLIENT INFORMATION (YOUTH ONLY)

Youth First Name

Youth Date of Birth

Youth Last Name

Current School (Use NA if not applicable)

CONTACT INFORMATION FOR SCHEDULING

Primary Phone

Secondary Phone

Email

Street Address

City

Region/State/Province

Postal / Zip code

COUNSELING REQUESTED

Select all that apply.

Youth

Adult

Family

Youth Group

Family Group

Reason for Counseling:

Behavioral Concern

Family Dynamics/Structure Concern

Family/Household Conflict

High Stress Level

School Conflict (current or past)

Criminal Justice Involvement (current or past)

Domestic or Interpersonal Violence (current or past)

Substance Use or Abuse (past or current)

Developmental Delay or Disability

Child Mistreatment or Welfare Involvement

Caregiver Mental Health Concern

Child/Youth Mental Health Concern

Parenting Skills Issue

School Engagement Issue

Social Support Concern

Other Notes

CAREGIVER INFORMATION

First Name

Last Name

Relationship to Youth

REFERRAL INFORMATION (if applicable)

Organization

First Name

Phone

Last Name

Email

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.

Contact Us

Connections Individual and Family Services

1414 West San Antonio St.

New Braunfels, TX 78130

Tel. 830-629-6571

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