Depressed? Anxious? Family problems?
Need someone to talk to?
We'd like to help.

You can take the first step in feeling better by talking to a therapist at Family Counseling Center. If you live in the middle Georgia area and would like to schedule an initial counseling session, you may either complete the form below and submit it immediately, fax (478-745-0881) or mail it to us. Someone from our staff will contact you the next business day after receiving your information. You may also call at 478-745-2811 to schedule an appointment.

Fields marked with a * are mandatory.

*First name:		MI:		*Last Name:

Spouse's name:

Children in home:

*Address:

*City:		*State:		*ZIP:

*Phone:				E-mail:

*Employment:				Work Phone:

*Soc. Security No.:			*Date of Birth:

*Sex:	male female			Marital Status:

*Ethnicity:	African-American Caucasian Hispanic Other

Who referred you to us?

Most convenient time for staff to contact you:

Questions or comments regarding your concerns:

After you have finished filling out this form, just to submit your information.

Depressed? Anxious? Family problems? Need someone to talk to? We'd like to help.

Depressed? Anxious? Family problems?
Need someone to talk to?
We'd like to help.