Mental Health Treatment Interest Form

    Please fill out the information below if you think you could benefit from Mental Health Services.

    Your Name (First and Last)

    Your Date of Birth

    Your Phone Number

    Your county of residence

    Do you have insurance? If so, what kind?

    What symptoms have you experience in the last 14 days?

    Please check which services you are interested in
    Individual TherapyCase ManagementMedication ManagementChild & Adolescent ServicesOther

    Any additional information you would like to share?

    After hitting 'submit', you will be contacted within 1 Business Day. Know that you are NOT alone!