Rawhide’s Youth & Family Counseling Appointment Request

Please complete the form below if you'd like to schedule an appointment with our therapist. You will be contacted by our scheduler shortly after your information is received.

If you have any questions concerning our program that you'd like answered prior to scheduling your appointment, please e-mail outpatient@rawhide.org.

Bold fields are required.



Your Information
Your NameYour Email
Client Information
First Name Middle Initial
Last NameBirth Date
GenderMarital Status
Address
CityCounty
StateZip
Phone Cell Phone
Best Time to Call
SSN Religion
Spouse/Parent(s) or Legal Guardians (If client is under 18)
Name
Address
Birth Date Relationship
 
Name
Address
Birth Date Relationship
Employer (if client is a minor list parent/guardian employer)
Employer Employer
Gross Family Income
Children (please list all children of the client and/or all children living in the home with the client)
Name Age DOB Gender Live with mom, dad, both, other