Start Counseling — Intake & Consent

Complete this secure form to begin. Choose whether you are an adult client or a parent/guardian for an under-18 client.

I am This switches the form between Adult vs Under-18 flow.

Contact & Basics

Full name

Date of birth

Phone / WhatsApp

City & State (current location)

Emergency contact name

Emergency contact phone

Main concerns

Hopes/goals

Any current thoughts of harming yourself or someone else?

If yes, anything you feel safe to share (optional)

I understand this is not an emergency service and will use 112/helplines in crisis.

Preferred format

OK to contact for scheduling/reminders via

SMS