JFK Counseling Center Inquiries and Information Request Form

Information Request Form
Please use this form to share general information about your inquiry. We kindly ask that you do not include any confidential or sensitive health details, as this form is intended for general requests only. If you'd like someone from our team to follow up with you, feel free to note that here.

⚠️ If you are experiencing a crisis or life-threatening emergency, do not use this form.
- Call 911 or go to your nearest emergency room.
- You can also call the National Suicide & Crisis Lifeline by dialing 988.
- Or text the word, HOME, to the number, 741741, to reach the Crisis Text Line.
If you would like to receive services, you may complete a referral form using this link: NU Community Counseling Center Referral Form
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Preferred Contact Method(s), select all that apply:*

Email: Please note we refrain from discussing personal details via email.Text: Please note we refrain from discussing personal details via text.Phone
Who are you inquiring for?*

YourselfA Child/DependentA client (for referral partners)Other
Reason for inquiry:*

Individual therapy (youth)Individual therapy (adult)Couples therapyFamily therapyGroup therapyWorkshopsI want to refer a clientInterested in learning more about your center/programsI'm interested in collaborating/partneringI'm interested in leading a training for staff/counselorsOther
If Interested in Group Therapy or Workshops, Please state any topics you might be interested in here:
Please share a quick description of your question (please do not include private/confidential details).*
How did you hear about us?

Google/Search EngineWord of mouthCommunity Event (please indicate details below)Referred by (if referred by an organization/agency/other) please indicate details below)Other
If you heard about us from a community event or were referred by an organization/agency/doctor/or someone else, please share details below. If you heard about us from a current or former client, please do not share their name and identifying information here.
Submission of this form does not establish a therapeutic relationship.

A staff member will follow up using your preferred contact method as soon as possible.
Should be Empty: