Request an Appointment

When life's stresses are too great, we've got you. The Village offers services that enhance the lives of individuals, couples, and families. Whether you're in need of counseling, addiction treatment, mentoring, financial advice, pregnancy help or adoption services, you don't have to go it alone.

To request an appointment with a Village counselor, please fill out the form below, and someone will get back to you within two business days. You may also call 1-800-627-8220 to speak to one of our intake specialists.

If you are an existing client, please log in to The Village Client Portal.

First

Middle

Last

Date of Birth (if requesting services)

Parent's Name (if request is for a child)

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

OK to leave message?

Yes

Are you accessing your Village EAP Benefit?

Yes

Unsure

Where do you (or the employee with The Village EAP benefit) work?

Will you be using Health Insurance?

Yes

Unsure

Insurance Company

Reason for Contacting Us (Referring Providers: Please Include Your Name)

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