Let’s work together

By completing this form, you are indicating that you have secured the clients explicit permission to share their PHI with Bettendorf Counseling Center and have a signed release on file if legally/ethically required.

Client Name

First Name

Last Name

Email

Phone

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Presenting Problem

Preferred Provider

If no preference, feel free to leave blank.

Referring Provider

Please include name, agency, and phone number.

Message

Join our team

As Bettendorf Counseling Center continues to grow, we are always looking for the right mental health professionals to join our team!

Name

First Name

Last Name

Email

Message