Counseling Center Tech Assistance Application

Technology Assistance Program

Regis Center for Counseling and Family Therapy
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Zip Code *
Are you currently a client at the Regis Center for Counseling and Family Therapy?

Yes No
I am interested in: *

Individual Counseling Family/Couples Counseling Child/Play Therapy
Are you in need of services provided in a language other than English? *

Yes No
Preferred Language
Most convenient times for us to call you (select all that apply): *

Mornings (9am-11am) Afternoons (12pm-4pm) Evenings (After 5pm) Weekends
May we leave a message/voicemail at the number provided? *

Yes No
How did you hear about our clinic?

Referral from another provider Referral from a current/former client Referral from a Regis employee Google Social Media Local Advertisement
Is there anything else we should know?
Should be Empty:

Technology Assistance Program