Services Request Form

Services Request Form

If you, or someone you care about, are experiencing a mental health and/or substance use disorder crisis, please call 911 for immediate assistance.
Name*
Age range*
Residence Town and/or Zip Code*
Gender
Preferred language*

CantoneseMandarinEnglishOther

Preferred way to contact*


Cell Phone
Text Message
Email

Preferred time to contact *

	Monday	Tuesday	Wednesday	Thursday	Friday
9am - 12pm
12pm - 2pm
2pm - 5pm

Area(s) of services you are seeking for*

Parent EducationFamily Wellness & Community EngagementCase Management & Integrated ServiceCounseling & Treatment Service
For Parent Education, which program(s) do you want to know more?*

Parent Solution 1: Introduction to American Public EducationParent Solution 2: Special Education: Laws & RightsParent Solution 3: Technology & EducationParenting JourneyStrengthening Families ProgramPositive Solutions for FamiliesInfant Massage
For Family Wellness & Community Engagement, which program(s) do you want to know more?*

AAPI Empowerment ProjectBrain Injury Recreational ProgramExpressive Arts Experiential ProgramParenthood Health Workshop SeriesMental Health First Aid Training (Adult)Mental Health First Aid Training (Youth)Special Arts Class
For Case Management & Integrated Service, which program(s) do you want to know more?*

Consultation & ReferralsCity of Quincy Office of Healthy Homes - Lead Abatement ProgramParenthood and MeRide the Wave
For Counseling & Treatment Service, which program(s) do you want to know more?*

Short-term Mental Health Counseling Service“Walking Beside You” Gambling TreatmentMother's Wellness Group
Which of the following symptoms and/or conditions are bothering you?

Anger, IrritabilityAnxiety, FearsDepression, SadnessParent-child relationshipStress and Time ManagementSelf-confidence or self-imageAdjustment difficulty in cultural living and learningConflicts with family membersOther
Are you currently receiving mental health counseling services?*

NoYes
Have you received any services from BCNC?*

NoYes
Any additional information you want to share with us?
If you have any enquiries about the above counselling services, the application procedures and related matters, Please feel free to contact Kit Yung, Family Services Manager at 617-249-2995 ext. 1065.

Boston Chinatown Neighborhood Center (BCNC) treats personal data as strictly confidential. Data is not disclosed to parties who have not signed a Disclosure/ Confidentiality Agreement unless authorized by federal mandate. Data is stored in confidential and secure platforms and accessible only by authorized personnel.

Mailing Address:

38 Ash Street, Boston, MA 02111 | 617.249.2995 | bcnc.net

Site Addresses:
- 38 Ash Street, Boston, MA 02111 | 617.249.2995
- 1458 Hancock Street, Suite 306, Quincy, MA 02169 | 617.770.0091
- Pao Arts Center, 99 Albany Street, Boston, MA 02111 | 617.863.9080
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