Family Services of Plano



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Counseling Request Form

** Free counseling services are offered for any family-related issue, as well as for crime victims. Clients 10 years of age and up are accepted. Fee-for-service counseling is available for individuals seeking anger management, Couple/Marriage counseling, and other non-family issues.

Please obtain/provide information for all sections on this referral form.

1. Client Information

Name of Client		Client Age
If client is a minor, name of Parents to contact to schedule an appointment:
Home Phone		Work Phone
Cell Phone		Email
Which is best way to reach you? Okay to Leave Message? Yes No
Best days / time for appointments?
How did you hear about Family Services?
If other or referral, please specify:

2. Reason for Seeking Counseling

Parent/Teen Issues	Family Violence / Victim-related Issues
Couple/Marriage	Anger Management
If other, please specify:

Other info that would be helpful for counselor to know:

A counselor will call to schedule your appointment.

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