Exceptional Family Member Program

* = Required Field

You will be contacted within one business day to schedule an appointment with a counselor.

Date Submitted: 14 Nov 2018
   Are you an active
   ID holder?:
Personal Information  
* First Name:
* Last Name:
   Relationship to Sponsor:
   Sponsor's Branch of    Service:
   Rank:
   Battalion/Company:
Contact Information  
* Primary Phone:
   Secondary Phone:
* Email Address:
   What brings you in for counseling?
   
   What location do
   you prefer:
   Best day and time for
   an appointment:
 

Information you provide will be kept confidential except to meet legal obligations or to prevent harm to yourself or others. Under certain circumstances an adult victim of domestic violence or sexual assault may elect to make a restricted confidential report. If you feel this applies to you, please call the Victim Advocate Helpline 703-350-1688 for more information. When requesting an appointment, do not leave restricted reporting information on this Appointment Request Form. This request line is only monitored during normal business hours. If you are experiencing suicidal thoughts, or this is an emergent situation, please call 911 or go to your local emergency room. You will be contacted within one business day to schedule an appointment with a counselor.