Let's Talk!

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Let's Talk!

Eden strives to provide the highest quality Client-Centered, Family-Oriented, Culturally and Contextually responsive, Trauma-Informed care.

If you are interested in receiving therapy services from a member of our team, please fill out this form to help us gather more information about you and your needs.

Please be reminded that the information in this form is not confidential and that no professional therapeutic relationship has been established.

Email *

Record my email address with my response

Name *

Phone Number *

Email *

When we reach out, is it OK to identify ourselves as a therapy clinic? *

Is it OK for us to text the number provided? *

Is it OK for us to leave a voicemail message at the number provided? *

How can we help? *

I'm interested in counseling or therapy for myself or my family

I would like more information about the 48-hour Crisis Receiving Home (CRH) for youth (8-17 yrs.)

Other resources

I want to stay in the loop. Please add me to your email list.

Other:

Clear form

Never submit passwords through Google Forms.

This form was created inside of Eden Counseling Services, Inc.

Does this form look suspicious? Report

Forms