Individual Therapy Request Form *

If you are making a request for someone else, please complete this form with the information of the person needing services.

First Name

Last Name

Phone *

(###)

###

####

Who is filling out this form? *

Select One

Self

Parent (please provide your information below)

Community Provider (please provide your information below)

Please check symptoms that you are experiencing *

anxiety

sadness

restlessness

crying spells

difficulty sleeping

difficulty with concentration

substance abuse

suicidal thoughts

flashbacks

mood swings

aggression

low motivation