Community Counseling Program Application

River City Advocacy & Counseling Center

1614 W. San Antonio Street, New Braunfels, TX 78130

www.rivercityadvocacy.org

Office: 830-643-0200

email: counseling@rivercityadvocacy.org
Community Counseling Program Application

Please allow 5-10 business days for us to respond to your submission. If you have not heard from us within that time, please call our office at (830)-643-0200 or email counseling@rivercityadvocacy.org. If you are in crisis and in need of immediate assistance, please call the MHDD Crisis Hotline at 1-877-466-0660 or the National Suicide Prevention Lifeline at 1-800-273-8255.
Due to current demand for counseling services, please be aware that scheduling for appointments may take up to 30 days. If you are in crisis, please call the hotline numbers listed above. If you need information on other mental health resources in our community, go to www.MapNB.com, www.211texas.org, dial 2-1-1 on your phone, or call our office at 830-643-0200.

Please note: If you are18 years of age or older, you must complete this form for yourself. Another person may not complete this form, schedule an appointment on your behalf, or request information about you or your status as a client from River City Advocacy & Counseling Center without your written consent.
Client Name*

First NameMiddle NameLast Name
Is client under the age of 18?
Parent or Guardian (if completing this form for a child under the age of 18)

First NameLast Name
Please choose the county in which you live.*
What is your zip code?*
Do you live inside New Braunfels' city limits?*
E-mail*
Phone Number*

Area CodePhone Number
Client Date of Birth*

MonthDayYear
Date
Do you have health insurance?*
Household Family Size*
Household Yearly Income*

$0 - $12,760$12,761 - $38,280$38,281 - $51,040$51,041 - $68,960$68,961 - $104,800$104,800 or more

Please mark your availability (select all that apply):

Rows	Morning	Afternoon	Evening	Any Time
Monday
Tuesday
Wednesday
Thursday
Friday

Type of Counseling *
Note: If you select Couples for Type of counseling, please provide the following information about your partner with whom you will attend counseling.
Name of Partner
First and Last
Partner's Email
example@example.com
Partner's Phone #

Area CodePhone Number
_______________________________________________________________________
Would you prefer telehealth or in-person counseling?

Telehealth (phone or video)In-personEither/No Preference
May we leave a voicemail at the phone number you provided?

YesNo
Are you a United States military veteran or dependent?

Military veteranMilitary Dependent spouseMilitary Dependent child under 21 (or under 23 if full-time student)None of the above
If you have a specific request about your counselor, please write here: ex. female/male or a specific counselor's name
How did you hear about RCA?
The following information is requested for grant reporting only.
Race/Ethnicity
Have you ever been a victim of any of the crimes listed below? Please Check all that apply.

Adult Physical AssaultAdult Sexual AssaultAdult Sexually Abused as a childArsonBullyingBurglaryChild Physical Abuse or NeglectChild PornographyChild Sexual Abuse/AssaultDomestic and/or Family ViolenceDUI/DWIElder Abuse or NeglectHate CrimeHuman Trafficking-LaborHuman Trafficking-SexIdentify TheftFraudFinancial CrimeKidnappingMass ViolenceOther Vehicle VictimizationRobberyStalking/HarassmentSurvivors of Homicide VictimsTeen Dating VictimizationTerrorismOther
Signature (use your mouse or finger to sign below)*
Should be Empty:

Community Counseling Program Application

The following information is requested for grant reporting only.