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    You Have a Friend Counseling Service

    Client Appointment Request Form

    You Have a Friend Counseling Service are provided based on the Ethical Standards of the American Counseling Association.  Your request for services and the information you share are considered confidential in accordance with these standards.  No information will be released without your written consent.  Please review the limits of confidentiality on the Consent for You Have a Friend Counseling Service information sheet.

    Fields marked with an (*) are required.

    Appointment Scheduling Information

    Name*:
     First

    Middle

    		          Last
    Client ID Number*:
     
    Client #
    Address: 
                                     Street
     
     City

    State

    		      Zip Code
    E-mail Address*:
    Reenter E-mail Address*:
    Telephone*:  Area Code - 
    Cell Phone:  Area Code - 
    Ok to Contact:
      Telephone
      Cell Phone
      E-mail
    Preferred Appointment Date and Time*:
    500 characters remaining
    Alternate Appointment Date and Time*:
    500 characters remaining
    Reason for Requesting an Appointment*:
    1500 characters remaining

    At busy times during the year, it is sometimes necessary for You Have a Friend Counseling Services to begin a waitlist in order to adequately serve those Clients already engaged in services through our office. Clients will be assessed through the intake process, but then may be placed on the waitlist or referred to other.

    Acknowledgements*

    I give consent for You Have a Friend Counseling Service to contact me regarding initiating services, understand that the service is not provided by a psychologist, social worker or other clinical professional, is based on educational and spiritual counseling principles and confirm that the information on this form is accurate to the best of my knowledge.