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Willowbrooke Counseling Center Appointment Request

Please compete the form below and someone will be in touch within 48 hours to schedule a free screening. If you need immediate help, please call 770-812-3266 or go to the nearest emergency department.

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1. First Name:
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2. Last Name:
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3. ZIP Code:
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4. Email Address:
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5. Phone Number:
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6. Best time of day to reach you:
7. If this is a referral, who is the person making the referral (referrer name)?
8. If this is a referral for school counseling, which school?
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9. Referral contact number:
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10. Parent or guardian name:
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11. Parent or guardian contact number:
12. Comment/questions (please do not include personal health information):
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13. How did you hear about Willowbrooke Counseling Center?
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