Counseling Referral Form

East Hartford Youth Services provides individual, group and family counseling for residents of the Town of East Hartford free of charge.

Client/Child's name *

Age *

Date of Birth *

Month

Day

Year

Address *

Parent/Guardian Name *

Child's School *

Phone Number *

Email address *

Referred by *

Parent

School

Other

Referral source Name/Phone if other than parent *

Please provide a summary of why the individual is being referred for counseling *

Counseling hours are 3-8pm Monday-Thursday, and 9-1pm on Saturdays. Is there a preferred day/time for the appointment? *

Leave this field blank

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