Full Name

Child’s Name (if necessary)

Child's Age (if necessary)

Phone *

Address *

City *

Postal code *

Email *

For whom are you seeking counseling?

Relationship to child or adolescent (if applicable)

Would you prefer a male or female counselor?

Would you like to receive online counseling (telehealth)?

Please provide at least 3 times you or your child/adolescent are available for counseling. *

What is the best way to reach you?

What type of therapy are you seeking?

How did you hear about us?

Briefly describe the issue(s) you’re seeking support for. Also, is there a specific therapist you’re hoping to work with?

Email Acknowledgement & Use Consent

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Silver River Counseling therapists and/or office staff communicating with me via email.