mental health resource connection contact us form

Child's first and last name

Child's date of birth

Child's sex

Second child's first and last name (if wanting to be seen for the same concerns)

second child's date of birth

second child's sex

Child's insurance provider (if none please put "none")

Parent/guardian's name

Parent/guardian's primary phone number

Parent/guardian's email address

Street address

City

State

Zip code

Issues/concerns (select all that apply)

Services needed (select all that apply)

Additional comments or questions

How would you like to receive information on resources?

03/27/23 | blog post 2 steps for Ohio Medicaid renewal Families covered by Ohio Medicaid for health insurance should take these two steps as soon as possible.

03/29/23 | blog post tips for teachers: 6 ways to reduce test stress for students use these strategies during state testing season

Low iron levels are common in children. Learn more about causes, symptoms and when to be concerned.

learn more