CMRN Intranet

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.







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.









Please provide a summary of the client's situation, the type of services they are seeking, and any special instructions.