Request An Appointment Hi, we are glad you reached out to get started with our Community Counseling Program. You can use the form below or Call 940-382-5112 to speak to our reception desk. First and Last Name * First Name Last Name Date of Birth * Date of Birth MM DD YYYY Phone Number * (###) ### #### Email * Email Address Address Address Which insurance are you covered by? * Private Insurance Medicaid Medicare Unfunded/ No Insurance Text * Annual Income * Below $5,000 $5,000 - $9,999 $10,000 - $14,999 $15,000 - $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $100,000 - Above Household Size * 1 2 3 4 5 6 7 8 9 10 Text Area What would you like to work on in counseling?
