CRC Austin - Information Request

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This form should take less than 5 minutes to complete.
The staff of CRC will do their best to hold any information shared with them in the strictest confidence. However, if there is information shared regarding the abuse or neglect of a child, older adult or person with disabilities, please be aware that as mandated reporters, our staff is required to file a report with the proper authorities within 24 hours.

All information submitted is encrypted, secure (SSL & this form feeds into a HIPAA compliant and encrypted version of G Suite). After you fill this form out, you will receive a response within two business day. (Note: If you are in crisis, please call 911)

Name *

Email *

Phone Number *

I am looking for help with: *

My own mental health

My marriage

My engaged or dating relationship

My child

My family

Other:

Required

Age of client? *

If you are inquiring about counseling for a minor, what is the current parental marital status or guardianship arrangement (ex: married (living together), married (living separately), divorced, never married, living with grandparents, etc)?

If you are inquiring about counseling for a minor, are there any special circumstances in the family (ex: adoption, child in foster care, specific form of trauma, early medical trauma, etc)?

What brings you to counseling? What goal(s) would you like to address? *

Which office locations work best? *

North Austin (11615 Angus Rd., Ste. 218, Austin TX 78759)

South Austin (2312 Western Trails Blvd, Suite B204, Austin TX 78745)

Cedar Park (507 Denali Pass Dr., Ste 301, Cedar Park, TX 78613

Round Rock (3000 Joe Dimaggio Blvd., Unit 30, Round Rock TX 78665)

Telehealth only

Required

Please choose the best option

I prefer a male therapist.

I prefer a female therapist.

I have no preference

Do you already have an idea of which therapist you would like to work with?

Do you attend a church in the Austin Area?

Yes

Clear selection

If so, which church do you attend?

Thank you for your inquiry.

Please note that the Center for Relational Care is out of network for all insurance companies. However, we offer a range of services at different fees depending on the experience level of the therapist. We will contact you by email at within two business days to follow up on your request.

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