Minor (under 18) or Family Counseling Request
Please use this form to submit a request for counseling for a MINOR (person under 18 years old) or FAMILY services with Emmaus Road (ERCC). Availability of therapist is not guaranteed, and you will be notified if a waitlist or other referrals are necessary.
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Parent/Primary Contact first and last name *
Parent/Primary Contact phone number *
Parent/Primary Contact email address *
Select all options you are available weekly to see a therapist. A therapist will contact you to schedule a specific time. *
Morning (9am-12pm)
Afternoon (12pm to 5pm)
Evening (5pm-8pm)
Not available this day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I am interested in... *
Minor's first and last name
Minor's client birthdate (including year)
MM
/
DD
/
YYYY
Were you referred to us through one of our partnerships?
In which location are you interested? *
If you are a pastor, please let us know at which church/denomination you serve:
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