Cornerstone Request for Services

Cornerstone Request for Services
Name
First Name*
Last Name*
Email*
example@example.com
Phone Information:
Country for Phone Number
Phone Number with Country Code
City and Country where you currently live
Sending Organization Name
Organization in the country that you serve
Passport Country
Our office prioritizes care for those we can meet in person and has limited availability for provision of online counseling. If we are unable to meet your request for online counseling, we can send you some outside recommendations. For those travelling to Chiang Mai to see us, we recommend that clients come for 2-3 weeks. Please do not make travel plans until you have appointments scheduled.
Please briefly explain the reason for your request*
Individual - AdultIndividual - AdolescentIndividual - ChildMaritalFamilyOnline CounselingOther
If 'Other', please explain briefly
By clicking "Consent & Send", you consent to Cornerstone Counseling Foundation collecting the personal data you voluntarily gave on this form for the purpose of coordination of services. If you do not consent, do not submit or send this form.
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