DeFrank Youth Space • Counseling Contact Form

Counseling Contact Form

Please call the 24 hour crisis line if you or someone you know is experiencing a crisis. (408) 850-6125

Fill in the form below to inquire about counseling at the DeFrank Center.
Counseling is free for ages 16 - 25.
*Required

*Your Name:

*Preferred Language:

Ethnicity:

DOB:

*Age:

Gender ID:

*Do you have insurance / what type?:

Current Living Situation:

Parent / Caretaker's Name (if appropriate):

*Address:

*Phone Number:

Type: Home/Family Work Cell

Is it ok to contact you at this number/leave a message?
YES NO

If not, are there specific contact instructions?

*Your E-Mail Adress:

Are you seeking individual, group, family counseling services, case management or psychiatry services?

Please tell us about why you are interested in counseling services.
Do you have any questions or concerns we should know about?

Confirmation code: Enter the code exactly as it appears. All letters are case insensitive, there is no zero.