Mental Health Self Client Contact Form

Mental Health Contact Request Form

Fill out the form below and one of our therapists will be in touch. *PLEASE NOTE- if you are experiencing a mental health emergency, call the Mobile Crisis Outreach Team (MCOT) 1-800-273-8255, or 911
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address*
example@example.com
Please provide the name of your insurance company, or indicate that you plan to self-pay.*

Self-PayInsurance (list insurance company below)Other
Have you accessed services at UAF before?*

YesNo
Please briefly tell us why you are looking for counseling services. *These answers are confidential.
How were you referred to mental health services at UAF?
Thank you for reaching out!

Our therapists will be in touch to discuss availability.
Should be Empty:

Mental Health Contact Request Form