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Serving Hands. Caring Hearts. Fostering Hope.

About Us
- Blog
- Strategic Plan 2025-2030
Adoption
Counseling
Family Life Education
Foster Care
Permanency Unit

Donate Now

Employment
News & Events
Many Ways to Give
Mission & Core Values
Family Portal

COBYS therapists encourage individuals and families to work through problems and find healing in broken relationships.

Counseling Inquiry Form

COBYS > Counseling Inquiry Form

The Counseling Inquiry Form is the fastest way to find out more information on available counseling services. Please complete the form and click the submit button. If you have not received a reply within 48 hours, please call 717-661-3548.

Note: Please respond to sections designated with an asterisk. These are required information.

COBYS Counseling Inquiry Form

Counseling Inquiry Form (1)

Counseling location preference*
- 444 Murry Hill Circle, Lancaster
- 134 E. King Street, Lancaster
- First available
My Name*
First Last
Relationship to Client*
- Self
- Spouse
- Parent of Client
- Pastor
- Adult Child of Client
- School (use Other)
Other*
Identified Client's Full Name*
First Last
Date of Birth*
Month
Day
Year
- Male
- Female
- Married
- Single
Cell Phone*
Home Phone*
Work Phone*
Phone Contact Preference*
- Cell
- Home
- Work
Is Voicemail Okay?*
- Yes
- No
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Is the client a child?*
- Yes
- No
Mother's Name*
Father's Name*
Who is the primary caregiver?*
Who has legal custody?*
Is this child adopted?*
- Yes
- No
Is this a foster child?*
- Yes
- No
Is this child going to be adopted?*
Is there a legal guardian involved?*
- Yes
- No
What is the guardian's name?*
Guardian's phone number*
Does the client have other services?*
(IEP, GIEP, TSS, BHRS, family-based, speech or occupational therapy, etc)? If yes, please explain:
Presenting problem(s):*
- ADHD
- Adjustment
- Anxiety
- Attachment
- Depression
- Divorce/Separation (Adult)
- Divorce/Separation (Child)
- Drugs & Alcohol
- EMDR
- Family Relationships
- Grief
- Marital
- Parent/child Relationships
- School Problems
- TF-CBT
- Addictions (list below)
- Other (list below)
Addictions:*
Addictions:
Other:
Other:
Additional information:
Is the client employed?*
- Yes
- No
Is the client a veteran?*
- Yes
- No
Is the client a student?*
- Yes
- No
Name of School:*
Name of School:
Does the client currently express harm to self or others?*
- Yes
- No
- They have in the past, but not currently
Current or past therapy?*
- Yes
- No
Dates/where:*
Dates/where:
Has client ever been psychiatrically hospitalized?*
- Yes
- No
Dates:*
Dates:
Previous outpatient treatment by psychiatrist?*
- Yes
- No
Psychiatrist name:*
Psychiatrist name:
Psychiatric diagnosis:*
Medications:*
Other current agency involvement:*
Insurance
Do you have insurance?*
- Yes
- No
Primary insurance*
Plan name:*
Other (if not listed):
ID#:*
Group #:*
Behavioral Health Phone:*
Name of insured:*
Date of birth of insured:*
Month
Day
Year
Do you have secondary insurance?*
- Yes
- No
Secondary insurance*
Plan name:*
Other (if not listed):*
ID#:*
Group #:*
Behavioral Health Phone:*
Name of insured:*
Date of birth of insured:*
Month
Day
Year
Appointments*
Appointments are weekdays only. Please list specific days of the week and/or times during the day that you are NOT AVAILABLE for appointments:
Other comments or questions:
How did you learn about COBYS?
- Brochure/flyer/pamphlet
- Newspaper
- Internet
- Church
- Pastor
- Friend/family
- Insurance Company
NOTE: After clicking the "Submit" button, you should receive a "Thank you" message page. If you do not receive that page, please check to make sure you have responded to all the required fields, otherwise our Counseling department will not receive your form.

Note: After clicking the “Submit” button, you should receive a “Thank you” message page. If you do not receive that page, please check to make sure you have responded to all the required fields, otherwise our Counseling department will not receive your form.

Foster Care • Adoption • Resource Home Unit • Family Life Education

(Main Mailing Address)
444 Murry Hill Circle
Lancaster, PA 17601
717-656-6580

The Counseling Center

444 Murry Hill Circle
Lancaster, PA 17601
717-661-3548

COBYS Permanency Unit

134 E. King St.
Lancaster, PA 17602
717-481-7663

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©COBYS Family Services. All rights reserved.

Services are provided without regard to race, color, religious creed, disability, ancestry, national origin, age, or sex.

COBYS Family Services is a registered 501(c)3 organization. A copy of our official registration and financial information may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania, 800-732-0999.

©COBYS Family Services. All rights reserved.

Services are provided without regard to race, color, religious creed, disability, ancestry, national origin, age, or sex.

COBYS Family Services is a registered 501(c)3 organization. A copy of our official registration and financial information may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania, 800-732-0999.