We're here for you.
See how we're keeping you safe.

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. You will see a "Thank You" message on screen after successfully submitting this form.

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

Please scroll to the top to see the confirmation message.
keyboard_arrow_up