Counselors of Texas :: Appointments

request an appointment

If you would like us to call you to schedule an appointment, please complete the information requested below. The information you provide will enable us to assist you as efficiently as possible. Our referral staff will contact you within two business days. If this is an emergency, please call (254) 778-4673.

	Patient Information

	First Name:
	Last Name:
	Phone:
	Email:

	Appointment Information

	Preferred Date:
	Preferred Time:
	Location:
	Type of Service:
	Issues:
	Other:
	Insurance:
	Age of Client: