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. * First Name * Last Name * Email * Telephone * 1. Patient First Name: * 2. Patient Last Name: * 3. Patient ZIP Code: 4. Patient Email Address (if different from the submitter email at the top of this form): * 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. Referral email address (if different from the submitter email at the top of this form): 13. Comment/questions (please do not include personal health information): * 14. How did you hear about Willowbrooke Counseling Center? ---Select One-- Ad (print) Ad (social media) Email Emergency department Family member Flyer Friend Primary care physician Psychiatrist Social media School counselor Seach engine (Google, Bing, etc.) Teacher Web site Word of mouth Security Code Type Security Code SUBMIT SUBMIT