Maintaining our commitment to excellence in Mental Health Services

Request for Services


We welcome your request for information and services. You may fill out the brief form below and click Submit below the form. Every effort will be made to contact you within five business days. We look forward to meeting you, answering your questions and providing services to your referrals!

This format is to be used by Facilities, Legal Guardians or Institutions only.

If you are an individual seeking counseling, please call our office during business hours.

"*" indicates required fields

Person making the request*

Facility Information

Contact Name*
Facility/Institution Address
This field is for validation purposes and should be left unchanged.