Get Help: Youth & Family Services

Get Help: Youth & Family Services

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.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select the option that applies to you:

What services are you seeking?
Youth Mental Health
Which county are you seeking services in?
Is the youth between the ages of 8 and 21?
Is this a WISe referral?
What is your company/organization?

Name of the youth:

First NameLast Name
What is your name?
What is the phone number of the person we should contact to schedule an appointment?
Format: (000) 000-0000.
Who does this phone number belong to?
Can we leave a detailed voicemail? If others have access to this voicemail and should not know you contacted us, select "No."

What is the email of the person we should contact to schedule an appointment?
example@example.com
Alternative email:
Ex. Email of the person submitting the referral
Date of birth for person needing services:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age (will say 54 until DOB is added):

Do you give permission for your parent/guardian to know that you are receiving services at THS? You are legally allowed to decline if you are 13 or older.
Note: If you don't want your parent/guardian involved and are worried about insurance, just submit your form and we will help you explore your options.
Emergency Contact Name and Phone Number
Parent, Guardian, Trusted Adult, School Counselor, etc.

Does the youth have health insurance? What kind?
Private insurance company:
Other insurance:

Which city does the youth live in?
What is the youth's zip code?
Would it be preferred/needed to receive services in a language other than English?
What language is preferred?
What school does the youth client attend?
Other School:
If not in school just type "not in school"
Based on your school selection, we may be able to offer on-site therapy at school. Are you interested in school-based services?

Is there anything else you'd like us to know?

0/750
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, and email.
Should be Empty: