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.
Parent/Primary Contact first and last name *
Your answer
Parent/Primary Contact phone number *
Your answer
Parent/Primary Contact email address *
Your answer
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 (1pm to 4pm)
Evening (5pm-8pm)
Not available this day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Minor's first and last name *
Your answer
Minor's client birthdate (including year) *
MM
/
DD
/
YYYY
Were you referred to us through one of our church partnerships?
In which ERCC location are you interested? *
Have this person seen a therapist at ERCC before? *
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