A Different Way. Counseling and Human Services

In ordering services from A Different Way you agree with the following:

You are 18 years of age or older
You have read and understand the applicable fees, service benefits and limitations as listed on the website
You are not currently suicidal or a threat to others

Please provide the following information.
Note: Items with a star(*) are necessary to process your request.
All other fields are optional - though helpful.

* First Name	* Last Name
Address
City	State
Zip Code	Country
* Phone	* Email
Occupation	Marital Status
Sex	* Date of Birth
Problem/Issue
PAST/PRESENT MEDICAL CARE (Specify: major problems, accidents, hospitalizations, current medication)
PAST/PRESENT COUNSELING/PSYCHOTHERAPY/PSYCHIATRIC HOSPITALIZATIONS
PAST/PRESENT DRUG/ALCOHOL USE/ABUSE (any addiction, AA/NA/etc.)
FAMILY HISTORY OF ALCOHOLISM, MENTAL ILLNESS, VIOLENCE, SUICIDE
* Verify Enter the code you see below

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