Counseling Referral | Connections

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Request counseling

NEW CLIENT INFORMATION

Youth's First Name

Youth's Last Name

Date of Birth

Current School (Use N/A if not applicable)

County of Residence

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

Select all that apply.

Youth

Adult

Family

Youth Group

Family Group

Reason for Counseling (Select all that apply):

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

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.
If you haven't been contacted in one week, please call 830-629-6571.

1414 W. San Antonio St.

New Braunfels, TX 78130

Tel. 830-629-6571

HELP A YOUTH IN NEED. DONATE TODAY.

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