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Still Waters Professional Counseling Services, Inc.
Still Waters Professional Counseling Services, Inc.
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  • Adopt-A-Family 2021
  • Satisfaction Survey – Referral Source

Staff Developed Resources

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  • Email
    admin@stillcorp.com
  • Phone
    706-955-9224
  • Fax
    706-955-9349
  • Address
    3711 Executive Center Dr.
    Augusta, GA 30907
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December 2021
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Step 1 of 8

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  • Still Waters Referring Employee Information

    Below is dedicated to the person MAKING the "Adopt-A-Family" referral. Note: We are ONLY taking referrals from Still Waters Employees this year.
  • MM slash DD slash YYYY
  • Please give the best phone number that you can be reached for questions concerning this referral.

  • Family Unit Information

    This section is dedicated to determining who is the head of household (responsible party) for this referral and to determine key contacts for questions.
  • Please list best reach phone number here.
  • IMPORTANT! Please list the number of people receiving gifts this year. Do not include the parent or guardian.
  • This online form accommodates inputing 6 children. If there are more than 6 children to submit you will need to do an additional form. Please indicate if you are submitting an additional form.
  • Please get a verbal consent from the Family Unit Parent or Guardian. By clicking this box the person referring is attesting to the verbal agreement.
  • I attest that the Family Unit - Parent or Guardian Listed above gave verbal permission to participate in the Adopt-A-Family Program.

  • Adopt-A-Family Gift Pick-Up Agreement

    This year, there will be (1) designated gift pick-up day. Please remind those who pick-up to abide by covid-19 protocol and to also bring a verification ID.
  • Gift pick-up will be at Revifify Church located at: 4350 Wheeler R. Augusta, GA 30907 (Please give this pick-up address to the referred family)
  • If the gifts are to be delivered, please list where they should go.
  • Please list all people who authorized to pick-up the gifts. All authorized must present valid identification.

  • Child 1

  • Please indicate months or years old below.
  • This section is optional, however, it helps in selecting certain gifts such as hair products.
  • Please list here any allergies or health issues that need to be considered while buying gifts. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.
  • List here ideas for gifts. Please be specific. Example: if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.
  • List only if child has a urgent needs. Example: Child really needs tennis shoes for school.
  • Skip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit!

  • Child 2

  • Please indicate months or years old below.
  • This section is optional, however it helps in selcting gifts such as hair products.
  • Please list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.
  • List here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.
  • List only if child has a urgent needs. Example: Child really needs tennis shoes for school.
  • Skip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit!

  • Child 3

  • Please indicate months or years old below.
  • This section is optional, however it helps in selcting gifts such as hair products.
  • Please list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.
  • List only if child has a urgent needs. Example: Child really needs tennis shoes for school.
  • Skip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit!

  • Child 4

  • Please indicate months or years old below.
  • This section is optional, however it helps in selcting gifts such as hair products.
  • Please list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.
  • List here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.
  • List only if child has a urgent needs. Example: Child really needs tennis shoes for school.
  • Skip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit!

  • Child 5

  • Please indicate months or years old below.
  • This section is optional, however it helps in selcting gifts such as hair products.
  • Please list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.
  • List here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.
  • List only if child has a urgent needs. Example: Child really needs tennis shoes for school.
  • Skip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit!

  • Child 6

  • Please indicate months or years old below.
  • This section is optional, however it helps in selcting gifts such as hair products.
  • Please list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.
  • List here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.
  • List only if child has a urgent needs. Example: Child really needs tennis shoes for school.
  • Skip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit!

  • Home
  • About Us
  • Our Services
  • Meet Our Team
  • Employment
  • FAQ
  • Resources
  • Projects
  • Employee Portal
  • Gallery
  • Staff Developed Resources
  • Individual Satisfaction Survey
  • Adopt-A-Family 2021
  • Satisfaction Survey – Referral Source
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