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
Other
Is there anything else we should know?
Submit
Should be Empty: