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The following form is for doctors, social workers, teachers, and other professionals to refer individuals and families for free counseling services. If you are looking for counseling services for your child, family, or yourself, please use the "Make an Appointment" button at the top of the page.

By submitting this form, you are confirming that you have spoken with the family about the referral for free counseling services. You also confirm that the family agrees to services and has provided consent to the referral.

The individual/family meets criteria determined by Addy’s Colors as a:

Thank you! We’ll be in touch.

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