Mental Health Resources Request

Name *

First Name

Last Name

Your Gender *

Male

Female

Transgender Male

Transgender Female

Nonbinary

Other

Want to speak to someone about your situation?

Check this box and a mental health navigator will call you to discuss appropriate options.

Phone

(###)

###

####

Best time to contact you during weekdays

10:00 a.m. - 12:00 p.m.

12:00 p.m. - 3:00 p.m.

3:00 p.m. - 6:00 p.m.

Can we leave a voicemail?

Yes

No

Are you reaching out for yourself or someone else? *

Myself

Someone else

Gender *

Male

Female

Transgender Male

Transgender Female

Nonbinary

Other

Race/Ethnicity *

American Indian/Alaskan Native

Asian

Black or African American

Hispanic or Latino

White or Caucasian

Other

Will insurance be used? *

Yes

No

Not sure

Are there any other payment options we should consider?

I can pay out of pocket

I need low-cost options

I need free options

Is this person currently receiving mental health treatment?

Yes

No

Has this person received mental health treatment in the past?

Yes

No