Counseling/Tele Mental Health Services Application Form

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Educational Transformation Centre offers counseling services by utilizing student interns who are completing their Masters Degrees in Clinical Mental Health Counseling. Our intern counselors are supervised by Licensed Professional Counselors. For more information, please call 434-484-0964.

Today's Date *

YYYY

First and Last Name *

Address *

Email address: *

Best Number to reach you at: *

School and County in which you are attending: *

Services Required: *

Individual Adult

Individual Child/Teen

Group

Required

For Child/Teen Individual Counseling Parent/Guardian Name(s) and Contact information: *

Briefly describe your interest in receiving counseling: *

Do you have a counselor preference? *

Male

Female

No Preference

Have you been to counseling before? *

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