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Intake Form

Tell Us About Yourself


 

What is THE INTAKE FORM FOR?

Here’s your chance to tell us why you need our services. Seeking help is the first step to strengthening your quality of life. If you are a self-referral and want to schedule a free 1 hour consultation please fill out this form.  

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Name

confidentiality NOTICE

This document, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential information and privileged information. Any unauthorized retention, review, printing, copying, disclosure or distribution is prohibited. txcross.com will keep confidential all information transmitted in this document except as is needed to connect a counselor with the person completing this document.