Counseling Inquiry Form

Please complete this form if you would like to speak with someone about receiving counseling from our Well-Being Institute or would like a referral to a LGBTQ+ affirming mental health provider. If you need to speak with someone immediately, please go to our Hotlines page to see a list of available hotlines.

Once completed, this form will be directed to Anna Dziechowski, the Director of our Well-Being Institute (WBI). Anna or a member of the WBI team will respond within 96 hours (four days).

Name

First Name

Last Name

Pronouns

Email Address

Phone Number

(###)

###

####

I am interested in:

I am looking for:

How did you find our about our counseling services?

The Community Center values both privacy and confidentiality. We do not share names or contact information outside of the organization. By checking below, I acknowledge that I understand this policy.

I understand

Counseling Inquiry Form

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