Background Color:
Background Pattern:
Forms 4 U: Remember – You must be over 18years old to complete this form. If you are having thoughts of hurting yourself or another person, go to the “Crisis/Emergency” page and follow instructions.

Online Questionnaire
Use this list to help make your choices:

Emergency Contact: (This can be a phone number for EMTs in your area, the local police force, a trusted family member, your doctor or counselor). 

I understand my responsibility to disclose truthfully and honestly and I have completed this form truthfully to the best of my ability at this time. I release Travis Psycho-Educational Services from any liability or unsatisfactory outcomes due to omissions and falsifications on my part during the course of our relationship.
* Required