No-Cost Counseling Program Request Form
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  • No-Cost Counseling Program Request Form

    Thank you for your interest in Crescent Counseling Center’s No-Cost Counseling Program. This program offers short-term counseling, up to 8 sessions, with a supervised counseling intern.This program is available for individuals ages 8 and older. For clients under 18, a parent or legal guardian must complete this form.This is not a crisis service. If you or your child are experiencing a mental health emergency, call or text 988, call 911, or go to the nearest emergency room.Completing this form does not guarantee placement in the program.

  • Eligibility and Screening Questions

  • Are you currently experiencing a mental health crisis or feeling unable to keep yourself or someone else safe?*
  • Is your request related to a court, custody, legal, school-disciplinary, or mandated issue?*
  • Are you looking for letters, forms, evaluations, disability paperwork, custody documentation, or legal documentation?*

  • Important Notice

    At this time, the No-Cost Program does not provide services for this request.

    • If you are experiencing a mental health emergency, call or text 988, call 911, or go to the nearest emergency room.

     

    • If you are looking for documentation, records, or additional support options, please return to our website to explore available services and resources.

    Click here to return to Crescent Counseling Center's Website 

  • Applicant and Contact Information

  • Request is for*
  • Date of birth*
     - -
  • Format: (000) 000-0000.

  • Counseling Need and Fit

  • What support needs best describe what you are looking for?
  • What days and times generally work best for you?*
  • Do you prefer in-person or telehealth appointments?*

  • Required Acknowledgements

  • Should be Empty: