Individuals desiring counseling services for themselves, or those in their care, need to complete the Counselee Services Intake form and submit it to us by secure email or fax (321.269.8173).

The Counselee Services Intake form is an Adobe PDF (Portable Document Format) file and a minimum version of Adobe Reader 5.0 is required. If you have don't have Adobe Reader or you have an older version than 5.0, you can download the most recent version free from Adobe's website. Follow their instructions for downloading and installing the program and then return to this page to download the form.

Click the link below to open the form in your browser. You can complete it online and print it directly from your browser, or if you prefer, you can click the Save icon in the browser document window to Save a Copy to your computer desktop.

NOTE: you will not be able to save any form data entered with the form using Adobe Reader only; a full version of Adobe Acrobat is required.

   

Counselee services intake form

   

If you have any questions or problems, please contact us.

Thank you!

 
   
  


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2801 Tropic Street, Titusville, Florida 32796 Phone: (321) 269-0404 Fax: (321) 269-8173

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