Thornwell Community Counseling Personal Inquiry Form Name(Required) First Last Best Phone Number(Required)Email(Required) Your Date of Birth(Required) Month Day Year Zip code where you reside(Required)County where you reside(Required)Therapy Preference(Required) In-Home Virtual Office School Based (Laurens 56) Therapy options are dependent on age of the child, your location, and providers available. We can discuss your preferences in your free consultation.I am interested in therapy for:(Required) Myself My child/teen My family Therapy options are dependent on age of the child, your location, and providers available. We can discuss your preferences in your free consultation.What goals/needs do you have at this time? (check as many boxes as apply)(Required) Stress Anxiety Depression Grief/Loss Marriage and/or Family Issues Anger Management Career Stressors School Stressors Behaviors Bullying Early Trauma and Attachment Issues Foster Care/Adoption related Issues Other How did you hear about the Building Families program?(Required) Doctor School A family who participated in the program Another professional involved with my family (Mental Health Counselor, Occupational Therapist, Speech Therapist, etc) Social Media Online search for help Other Name of Referral SourceThornwell Email Updates Consent(Required) I would like to receive updates from Thornwell.By checking this box, you are agreeing to receive email updates from Thornwell Community Counseling. Your information will remain private and used only for informational purposes on your behalf.
