Name *

First Name

Last Name

Phone *

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I Acknowledge *

I acknowledge I am 18 years of age or older.

I understand Balance & Recovery Counseling cannot guarantee privacy of the information submitted through this digital form.

I acknowledge that I can communicate this information over the phone at 706-363-5033, if I wish to submit this information with ensured privacy.

I am not feeling actively suicidal or wanting to harm another person and will access the resources with the help of the resource button, if I need help before BARC can contact me.