Request Service

Request for Service Page

This page allows you to securely send us the information we need to contact a military client in need of our services. It eliminates the insecurity of sending personal information over email. You may still send us email at info@civilianmedicalresources.net, but do not include any sensitive or personal client information within an email - use this form. You may send us a request to be added to our database, which contains a secure method of communication, if you wish to continue working with a client.

Counselor Information

Please provide your contact information below.

First Name:	Last Name:
Organization:
Phone:	Email:
City:	State:

Client Information

At the very minimum, please provide at least a first name and a phone number or email address for us to contact the client.

First Name:	Last Name:
Phone:	Email:
City:	State:
Gender:	Branch:
Case Summary: Please provide a summary of the client's situation, the type of services they are seeking, and any special instructions.