Request Form

First name *

Last name (surname/family name)*

Date of birth*

Identified gender

Ethnicity

Hispanic

Non-Hispanic

Are you a current K-State student?*

Yes

No

If Yes, what department?

Phone*

Is it okay to leave you a voicemail?*

Yes

No

Email*

Is it okay to email you?*

Yes

No

Mailing address*

Address line 2

City*

State*

Zip Code*

Please select the number of people who currently live in your household*

Please indicate your current annual household net income (after taxes)*

Have you ever been a client of the Family Center?

Yes

No

Are you part of the USD 383 Early Learning Community?

No

Yes, College Hill

Yes, Eugene Field

What type of therapy services are you seeking?*

Individual

Couples

Family

Premarital Counseling

Are you interested in: *

In-person therapy

Teletherapy (online therapy)

Please let us know your preferred time for weekly therapy sessions

Please give a brief description of the reason you are seeking therapy services?*

If this request is for therapy for a couple or family, please list the name(s) of who will be attending sessions with you:

Request for Therapy Services