Appointment Requests

If you are concerned about yourself or about somebody else, please call the crisis hotline. This will connect you to your closest crisis center Crisis hotline:

1-888-568-1112 or National Suicide Prevention Lifeline:
1-800-273-TALK (8255)
Are you making a referral for someone else?
First
Last

Client Information

First
Last
Does the client have a guardian?
Street
City/Town
State
Zip Code
Is the individual (client) seeking service a class member?
What gender would the individual (client) prefer their provider to be?
Has the individual (client) ever served in the U.S. Armed forces?

Services Requested

Preference for Services (mark all that apply):
Are Interpreter Services needed?
Please select the services you are requesting
Case Management Type
(Please include the provider's credentials. ie: MS, LSCW, MHNP, LCPC, MD)
Living Situation
Employment Status
Does the client have a history of violence/aggression?
Does the client have a history of substance abuse?
Alcohol or substances.

  • Please note: we may not accept all insurances.

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Coronavirus/COVID-19 Alert - The health and safety of our affiliates, staff, case managers, and clients is our top priority. Our COVID-19 Updates page provides current information about how we are working together to help keep our communities safe. Learn More

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