Counseling Inquiry Form

Counseling @ Center Point

Appointment Request Form
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred contact method
Service Needed
Counseling Services: Support for counseling and therapy needs. We provide professional counseling services for children, teens and adults.

Local Victims Assistance Program: Support for victims of violent crimes as determined by the State of Georgia Victim Compensation Guidelines.
Which service do you need?
Briefly describe your counseling related concern.
If you will be using insurance, please list your plan name below.
If you were referred by a provider, please list their name below.
Please note that submission of this form is not a guarantee of services. For confidentiality reasons you will not recieve a confirmation or reciept emailed to you. Please know that your request has been recieved. If you have any questions please don't hesitate to call us directly at 770-535-1050 ext 106. Thank you!
Should be Empty:

Counseling @ Center Point