TEXT_Make_An_Appointment

 

To make an appointment with a BYS therapist, please fill out the form below. We provide free confidential psychotherapy services to youths (ages 13 and up) and parents. (We do not offer testing and assessment services.)

If this is an emergency, call 911. If you are in a crisis or need to talk to someone immediately, please call the Crisis Clinic of the Peninsulas (24 hours) at 360-479-3033 or 1-800-843-4793.

Forms with incomplete or incorrect emails cannot be processed. Please double check your information before hitting “Send”. You will get a confirmation email in a few minutes. If you do not see a confirmation email, please resubmit, or call us at 1-206-842-9675.

I would like a phone consultation with a counselor before I make an appointment

Date of appointment request:

This appointment request is for:

Youth's First Name Youth's Last Name

Youth's Age (required):

Youth's Email (required):
PLEASE CHECK YOUR EMAIL. AOL and yahoo users may not receive confirmation due to filter issues. You may use frogrock.org email only if you are a high school student (not middle school or younger).

Youth's Phone # (required):
You can leave a voice mailYou can text me

Who is requesting this appointment? (required)
I am requesting an appointment for myselfI am helping this person set up an appointment

________________________________________________________________________________________________________

If you are helping someone request an appointment, please let them know BEFORE you send the request.

Name of person helping:
Relationship:

Contact Information:

Email:
Phone:

________________________________________________________________________________________________________

Residency (required):
I am a resident of Bainbridge Island or go to school hereI live outside of Bainbridge Island
Youth who live in Kitsap County are eligible for our psychotherapy services.

Youth's current school:

Therapist preference:
Female therapistMale therapistEither is ok

Have you been to BYS for therapy before?
I am new to BYSI've been to BYS before, and would like to work with the same person if they are availableI've been to BYS before, and would like to work with someone newI've been to BYS before, and any therapist is ok
Last time at BYS, I've worked with (if you don't remember you can write "I don't know"): (Leave blank if this is your first time contacting us.)

How did you hear about us?

What would you like to get out of counseling?:
(200 characters available)

By clicking “Send”, I affirm that I have read and agree with the above statement, the terms set forth in the User Agreement, the Intellectual Property Disclaimer, and the information included in the FAQ Section.

Due to the unsecured nature of email the Internet, BYS cannot guarantee the confidentiality of your request. The request will be processed by BYS office staff, and sending a request does not automatically establish a clinician-patient relationship. Please be aware that your message or our response could be intercepted by a 3rd party. If this is a concern, call us at 1-206-842-9675.


You will get a confirmation message below, and an email in a few minutes. If you do not see a confirmation email, please resubmit, or call us at 1-206-842-9675. Thank you.