Counseling Referral Request

If you or someone you love is navigating a difficult time or struggling with mental health concerns, you are not alone, and we want to support you. Providing the information below will help us direct you to counselors or resources that will be able to offer the care you need.

Your name *

Email address *

Phone number *

Address *

Birthdate *

Which COTC location do you attend? *

Please select which option(s) most accurately describes your need. *

If you need both referrals and assistance, please check both boxes.

I am interested in receiving counseling referrals.

I am in need of financial assistance for counseling.

If you are requesting referrals for someone other than yourself, please identify his/her relationship to you and his/her age. *

Please share any information that might assist us in providing the most appropriate and helpful referral options. *

Counselor Preference *