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
Street
City/Town
State
Zip Code
Is the individual (client) seeking service a class member?

Services Requested

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)
Does the client have a history of violence/aggression?
Does the client have a history of substance abuse?
Alcohol or substances.