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Outpatient Mental Health Counseling
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Request Outpatient Mental Health Counseling
Request Comprehensive Community Services (CCS)
Request Brainspotting
Request First Responder Services
Request First Responder Group Services
Request Supporting The Supporters of First Responders Services
Request Group Services
Request Supervision Sessions
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Our Mission
Our Team
Insurances Accepted
Resources
Careers
Liability Waiver/Confidentiality
Our Services
Outpatient Mental Health Counseling
Comprehensive Community Services (CCS)
First Responders/Critical Incident Stress Management
Brainspotting
Group Services
Consultation & Training
Supervision Sessions
Practicum & Internships
Request Services
Request Outpatient Mental Health Counseling
Request Comprehensive Community Services (CCS)
Request Brainspotting
Request First Responder Services
Request First Responder Group Services
Request Supporting The Supporters of First Responders Services
Request Group Services
Request Supervision Sessions
About Us
Our Mission
Our Team
Insurances Accepted
Resources
Careers
Liability Waiver/Confidentiality
Client Portal
Request Comprehensive Community Services (CCS)
To see provider availability, please visit this page
.
If you are requesting outpatient services,
please use the
Outpatient Mental Health Counseling form
.
Refer a Consumer
Referring Agency Name
*
Referrer Name
*
First Name
Last Name
Referrer Phone
*
(###)
###
####
Referrer Fax
(###)
###
####
Referrer Email
*
Services Being Requested
*
Check all that apply. Include details in the "Other Information" section below.
ISDE
Psychoeducation
Psychotherapy
Wellness & Recovery
What days of the week and times of day is the consumer available?
*
Consumer Information
Name
*
First Name
Last Name
Email
*
Date of Birth
*
MM
DD
YYYY
Age in Years
*
Gender
*
Male
Female
Transgender Male to Female
Transgender Female to Male
Non-binary
Intersex
Prefer not to answer
Preferred Pronouns
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
(###)
###
####
School District
Include if consumer is under 18.
Guardian Information
Guardian/Parent Name
Guardian Relationship
Guardian Contact Information
Presenting Issues and Symptoms
*
Current Diagnosis
*
Please share current diagnosis and/or medications including the name of prescribing doctor.
Goals
*
Please share goals to be accomplished through services.
Other Information
*
Please share strengths as well as any other relevant information, including any current services.
Thank you! You have been added to our waiting list.