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If you're experiencing a medical or other emergency, call 911 immediately. If you need urgent mental health support, call 988 immediately. You'll be connected to your local crisis support hotline.
Name

First NameLast Name
Date of birth
Please format like this: 01/01/1990
Is the person needing services 18 or under?
If the person needing services is 18 or under, please fill out our Youth Get Help form: https://form.jotform.com/210525164588155

Phone number
Format: (000) 000-0000.
Can we leave you a voicemail? If others have access to your voicemail and should not know you contacted us, select "No."
Email
example@example.com
What's your preferred method of contact?
What city do you live in?
What is your zip-code?

Please select the services you are interested in: *
(choose one or more)
Opioid Use Treatment
Suboxone Treatment
Mental Health
Alcohol / Drug Treatment
Psychiatric Services/Medication Management
Youth Mental Health
Youth & Families Services
Are you pregnant?
Note: If your medication supply is running low, please contact your current prescriber for refills. We cannot guarantee your first appointment date or that medication will be prescribed, as prescribing decisions are made at the discretion of our psychiatric practitioners.

Please share any details you have about the services you need

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By providing the information in the contact form above and submitting this form electronically, I am authorizing Therapeutic Health Services to communicate with me via phone call, text message, or email.
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