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 SUBMIT SUBMIT