Charis Counseling Centers

Your Name (required):

Your Email (required):

Your Phone Number (optional):

Subject:

Name of Insurance Provider:

Name of Policy Holder:

Identification Number of Primary Client:

Date of Birth of Primary Client:

Please describe your concern for our client intake coordinator. Please include the number of people who are seeking counseling and your relationship. For example: individual, parent-child, husband-wife.

Brief Description of Your Concern: