General Counseling Request Form

Submission of this form is not a guarantee of services at Mission Hills Counseling Center. At times cases are referred out at the discretion of the Director of Mission Hills Counseling Center.

  • General Information

  • Extent of Need

  • ** If you are in a life threatening situation, please dial 911 or contact your local authorities. **
  • Spiritual Information

  • Health Information

  • Symptom & Issue Checklist: (Please check all that apply)

  • Family Information

  • Date Format: MM slash DD slash YYYY
  • Employment Information

  • Scheduling Preferences

  • Please note that all appointments will be based on the counselors' availability.
  • This field is for validation purposes and should be left unchanged.