Video Counseling Request Form

Now Hiring State-Wide Make A Referral Areas We Serve Frequent Questions Make A Payment

Please complete the form below. Once complete, you will then be transferred to a secure PayPal webpage to complete the payment. Please note you do not need a PayPal account, you can securely pay via credit or debit card.

Once we have received the form below and confirmation of payment, we will contact you via email or phone to schedule your online video session and with further instructions.

Participant Rights for Outpatient Services

Procedures For Client Grievances and Other Issues

Consent for Treatment

Participant Orientation Summary