Printer-friendly version mental health resource connection contact us form 1 Start 2 Complete Child's first and last name * Child's date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Child's sex * - Select -MaleFemale Second child's first and last name (if wanting to be seen for the same concerns) second child's date of birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200120022003200420052006200720082009201020112012201320142015201620172018201920202021 second child's sex - None -MaleFemale 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) * ADHDAnger issuesAnxietyAutismBehavior problemsDepressionEating disordersGriefSubstance abuseTrauma Services needed (select all that apply) * Counseling/TherapyPsychiatryPsychologyAutism testingADHD testingEducational testing Additional comments or questions How would you like to receive information on resources? * - Select -By mailEmail
