New Client Request Form

*Please be aware that this form does not utilize encryption technology to transmit or store information, meaning whatever you submit could conceivably be intercepted by a third party. By using this online form you agree to hold harmless Adulteen Counseling, LLC and its representatives from all liability resulting from any breech of confidential information. Those with security concerns may submit their request for services verbally by leaving a message at 715-629-7047, ext. 201. Please allow additional time for processing of verbal requests.