Request for Services Please answer the questions below and we will follow up with you within 3 business days. Note: not all services are available in all school districts. "*" indicates required fields Δ Your Name* First Last Your Phone*Your Email* Who are you filling this form out for?* Adult Client Under 18 or Current K-12 Student Adult ClientsWhat services are you interested in?*(check all that apply) Outpatient Therapy Parenting Classes Other Other*Name of Adult (if different from person filling out form) First Last Phone Number of Adult (if different from person filling out form)Email Address of Adult (if different from person filling out form) Date of Birth of Adult* MM slash DD slash YYYY Type of Insurance Medicaid Medicare Private Insurance No Insurance A copy of your responses will be emailed to the address you provided. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Client Under 18 (or current K-12 student)Name of the child/student for whom you are requesting services.* First Last Child/Student's Date of Birth* MM slash DD slash YYYY Name of Child/Student's School District*Name of Child/Student's School Building*What services are you interested in?* School-Based Therapy School-Based Case Management School-Based Mentoring (iC.A.R.E. Mentoring) School-Based Health and Wellness Services Early Childhood Consultation Parenting Classes Mental Health Screening Outpatient Therapy Other Select AllOther*Have you spoken to the parent/guardian about these services?* Yes No I am the parent/guardian. Parent/Guardian Name* First Last Parent/Guardian Phone Number*Parent/Guardian Email* Type of Insurance Medicaid Medicare Private Insurance No Insurance A copy of your responses will be emailed to the address you provided. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
