Youth Under 16

*Please be advised, that at this time, we have an extensive youth waiting list and are unable to provide time frames for expected services.*

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 through SIGN NOW the business day following your submission. 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 a minor child under the age of 16.
If your child is 16 or older please have them complete the Individual Intake Form.

* Indicates required field

Child's First Name: *

Parent's/Guardian's Name: *

Phone Number *

Can we leave a voicemail? *

Email *

Military/First Responder Affiliation *

If Active Duty, is the service member stationed at Ft. Campbell? *

If First Responder, is the first responder serving in Montgomery Co? *

Date of Birth *

Have you or a family member received services with SAFE previously? *

Name of individual who received services previously. *

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

Is there DCS involvement? *

Is this counseling court ordered? *

If yes to any, please share information. *

Submit