CCD Request for Services V202505

Complete this form to request services at any of our CCD Counseling offices. Once we receive this, we will email you to schedule, or to follow up with additional questions.

If this is a life-threatening emergency, please call 911!

If this is not an emergency, but you need attention more quickly than we can provide, please call one of these other agencies:

Denton County MHMR - Call 800-762-0157

Dallas County Metrocare - Call 866.260.8000 or 844.672.5700

Which Service are you requesting?

Substance Abuse EvaluationCo-Parenting ClassFree Family Counseling for Youth and their FamiliesAll other Counseling (Individual, Couples, Play...)Other

Here is the wepage to request a substance abuse evaluation: Alcohol/Drug Evaluation

Here is the webpage to sign up for our Co-Parenting Class: Co-Parenting Class

Here is the website for our Family Tree Program that provides free family counseling for eligible youth and their families: https://familytreeprogram.org/

New Client Name*

First NameLast Name

Is the new client an adult and able to consent for their own services?*

YesNo

Client's current age

Consenting Adult

First NameLast Name

Relationship to Youth

Contact Email - This is the email we will use to contact you. Please provide an email that you regularly check. If you don't hear from us, be sure to check your Spam or Junk folders.*

Confirmation Emailexample@example.com

Briefly describe the challenges you hope to resolve in counseling OR if you are not seeking counseling, describe the service you are seeking:*

Location Preference

DentonLewisvilleFarmers Branch

What pay source will you be using?*

Self Pay (You can choose any therapist)Insurance or EAP (We need to find someone on your provider list)Another Pay Source

We are happy to help, but if you like, you can contact any of our therapists directly. Here is where you will find their webpages, as well as contact information (email, phone and text): Therapist Directory

Which Insurance or EAP are you hoping to use?

Preferred days/times for your counseling:

Please provide any additional information that might help us find you the best therapist/ service: