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Please complete this form to be added to our waitlist
. When we have reached your name on the waitlist
we will send you our intake paperwork via email
. This paperwork must be completed in order to move forward with services.
Once the intake paperwork is complete we will reach out to schedule an intake appointment. All of our intake appointments are conducted over Zoom.
Please only complete this form if you have discussed Couples Counseling with your spouse
.
*
Indicates required field
First Name and Last Initial
*
Phone Number
*
Email
*
Military/First Responder Affiliation
*
Active Duty
Active Duty Spouse
Active Duty Child
Veteran
Veteran Spouse
Veteran Child
FR-Fire
FR-Fire Spouse
FR-Fire Child
FR-Police/Sheriff
FR-Police/Sheriff Spouse
FR-Police/Sheriff Child
FR-EMT
FR-EMT Spouse
FR-EMT Child
Spouse's First Name and Last Initial
*
Spouse's Phone
*
Spouse's Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Are you and your spouse living separately or together?
*
Together
Separately
If living separately please list your spouse's address:
*
Line 1
Line 2
City
State
Zip Code
Country
Soldiers and Families Embraced does not provide counseling for legal purposes or DCS involvement. If you are seeking counseling for either of these reasons SAFE will not be able to provide you services but would be happy to give you resources to other mental health agencies that will.
Do you or your spouse have any open legal cases (including criminal, divorce, custody, etc)?
*
Yes
No
Is this counseling court ordered?
*
Yes
No
Is there DCS involvement?
*
Yes
No
Submit
DONATE
WHAT WE DO
WHO WE ARE
About SAFE
CLIENT TESTIMONIES
GET INVOLVED
EVENTS
CAREERS
INTERNSHIPS
CLIENT PORTAL
GIVE FEEDBACK
Request Services
Contact Us
News
Mental Health Resources
Local Resources
Crisis/Resources
Military/Veterans
First Responder Resources
Drug and Alcohol Misuse
Other Resources