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Families First Counseling Services is one of the leading providers of family-based, in-home and in-office counseling and therapy services in Iowa. We are a nationally accredited agency and employ many highly trained and skilled employees. Our staff can help the entire family develop skills to better cope with the daily stressors of everyday life.

  • Initial Referral Form for In Office Therapy Services, BHIS Services, IHH

    * - Indicates required field

  • Service Requested

  • Referrer Information

  • Referral Information

    • Responsible Party Information

    • Does the responsible party have legal rights to sign?

    • Legal Rights Party Information

  • Additional Information

  • Does the referred person have a State ID Number?
  • Do you know the type of insurance that will be used?
  • Please select from the following:
  • (Please submit insurance card; both sides will need to be copied)
  • Would you be agreeable to telehealth?
  • Would you be agreeable to Services in the school (if appropriate)?
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