Individual Counseling (16+)

Please complete this form to be added to request services, we will send you our intake paperwork VIA EMAIL through SIGN NOW the business day following your request. This paperwork must be completed within 72 hours 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 and completed between the hours of 10am and 3pm.

*Please only complete this form on behalf of yourself. All individuals 16 and older must consent to their own treatment.*

* Indicates required field

First Name and Last Initial: *

Email *

Military/First Responder Affiliation *

If Active Duty, are you stationed at Ft. Campbell? *

If First Responder, are you serving in Montgomery Co? *

Phone Number *

Can we leave a voicemail? *

Date of Birth *

Have you or anyone in your family received services with SAFE previously? *

Name of person who received services previously. *

Address *

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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 have any open legal cases (including criminal, divorce, custody, etc)? *

Is there DCS involvement? *

Is this counseling court ordered? *

If yes to any, please provide information. *

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