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? DepressionAnxietyTraumatic StressInattentionMood SwingsHallucinationsSleep Problems 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!