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Center for Counseling Inquiry Form
Please complete this form for each individual inquiring about counseling services. Our Client Relations & Billing Coordinator will be in touch within five business days to follow-up on your inquiry. If you are having a mental health emergency, please call 911 or go to your nearest emergency department.
Family Service Agency is a safe, inclusive space for all. We do not discriminate and proudly welcome LGBTQIA+ individuals, immigrants, people with disabilities, and anyone seeking support. You belong here.
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Guardian's Name (if client is under the age of 18)
First Name
Last Name
Guardian's Date of Birth (if client is under the age of 18)
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about FSA's Center for Counseling?
*
Have you received counseling services with Family Service Agency before?
*
Yes
No
Unsure
Other
Why are you seeking counseling services?
*
What type of insurance do you have?
*
How would you like to receive the intake paperwork?
*
Emailed
Pick it up from Family Service Agency
Safety Considerations: is there anything we should know to help keep you safe? (ex: don't call after 3:00pm, prefer to communicate via email, don't leave voicemails, etc.)
Please use this space to provide any additional information you think we should know
If you have additional questions, please contact us at 815-758-8616.
Submit
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