mental health resource connection contact us form Child's first and last name Child's date of birth Child's sex - Select -MaleFemale - Select - 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 - None -MaleFemale - None - 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 - Select - CAPTCHA
