Client Interest Form

Thank you for your interest in the Travis County Counseling Center. We offer free, short-term individual counseling services provided by master's level clinical social work interns under the supervision of a Licensed Clinical Social Worker (LCSW). Counseling can be a helpful space to explore challenges, manage stress, and build coping skills. It’s a supportive, nonjudgmental environment where you can focus on your well-being and personal growth.

Name

First NameLast Name

Date of Birth*

Date

Age*

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Is it ok to send a text message to this phone number?

YESNO

Is it ok to leave a voicemail?

YESNO

Email

example@example.com

Preferred Contact Method (check all that apply)

Phone CallEmailText Message

Race

Ethnicity

Gender

Gender Self-describe

Client Pronouns

Client Pronouns Specified

How did you hear about us? Please select the program

Community Center

Who referred you?

Reason for seeking support (check all that apply)

Life Transitions & AdjustmentsGrief and LossStress & Anxiety ManagementMild to Moderate Mental Health ConcernsConflict Resolution & Relationship IssuesBehavioral or Emotional ChallengesSupport for Medical or Health Related ConcernsSchool-Related Concerns

Briefly describe the reason for seeking support:

The next step is a short phone call to gather more information about your needs and help schedule your first counseling appointment. If you selected texting as your preferred way to be contacted, we’ll start by sending you a text to set up the call. Please note that text messages are not encrypted, which means there may be some privacy risks associated with this form of communication. Someone will contact you within three business days of submitting this form.

What is your availability for the phone call to gather more information? (check all that apply):

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Morning
Afternoon
Evening

Travis County Notice of Privacy Practices

As part of receiving services, you have been given access to the Travis County Notice of Privacy Practices. This page outlines how your protected health information may be used and disclosed. Please take a moment to review it at the following link:
https://www.traviscountytx.gov/topics/compliance-and-privacy

I give my permission for the Travis County Counseling Center to contact me about counseling services. I understand that completing this form helps the Counseling Center learn how to best support me, but it does not guarantee that services will be available. I also understand that I have the right to opt out of being contacted at any time by notifying the Counseling Center via email at counselingcenter@traviscountytx.gov or calling 737-228-5785 and leaving a voicemail.

Signature

Date

I certify that I am the parent or legal guardian of the child identified in this consent form. I have read and understood the information provided and give permission for my child to be contacted by the Travis County Counseling Center.

Parent/Guardian Signature

Parent/Guardian Name

First NameLast Name

Parent/Guardian Relationship to Minor

Parent/Guardian Signature Date

Date

Travis County Counseling Center - Client Interest Form