Counseling Request Contact Form

Contact Request Form

Boys & Girls Clubs of Garden Grove | Family & Youth Outreach Program | 714-741-5895
Low Cost Mental Health Counseling for All Individuals and Families

Please fill out this form and we will contact you as soon as we can. Are you a school official or referring agent? Visit https://bit.ly/chs-referral for our referral form.
Please enter today's date.*

MonthDayYear
What is your first and last name?*

First NameLast Name
What is your phone number?*
Format: (000) 000-0000.
Do you prefer a phone call or text message?*
What is your email address?*
example@example.com
What is the full name of the person needing services?*

First NameMiddle NameLast Name
What is their date of birth?*

MonthDayYear
SelfSiblingParentGrandparentCaregiverTeacher/AdministratorOther
Individual counseling (5+)Family counselingCouples counselingDrug education group (14-18)Character building group (14-18)Anger management group (14-18)Juvenile Offender Education (Both parent & child required to attend)
What are the preferred appointment days/times for the person needing services?
(i.e. Mondays after 3pm)
What are the best days/times to reach you?
(i.e. Weekdays after 3pm, any time weekends)
Should be Empty:

Contact Request Form