EPW Interest Form and Waitlist 2024

Emotional and Physical Wellness Department Interest Form

Hi! Please fill out this form and one of our staff will contact you in 5-7 business day to speak further. Additionally, for the safety and health of everyone we ask you wear mask when attending any classes and/or appointments.
Who is filling out this form?*

SelfReferring organization

Mental Health Waitlist - Adults

These questions will help us to get to know you, your mental health history, and your current needs. At this moment, we are at full capacity and are not currently able to provide you with mental health care. Answering these questions will allow us to give you an official spot on our waitlist and reach out if we can offer other internal referrals. All answers are confidential. If you are in mental health distress or having a mental health emergency, please contact the Emergency Mental Health Line at BHR (1-800) 811-4760 or (314) 469-6644, or the Suicide Prevention Line at 1 (888) 628-9454. We hope to be able to serve you soon!
Date of Birth*

MonthDayYear
Date
Are you a LifeWise StL Participant?*

YesNoPrefer not to answer
Do you have a preferred LifeWise therapist? Please enter their name. If no, type "first available".*
Do you prefer in-person or virtual?*

in-personvirtualeither
What is your availability?

Morning (8:00 - 11:59 am)Afternoon (12:00 - 3:59 pm)Evening (4:00 - 5:59pm): If you choose this time you will likely be waiting longer as these times are in high demand

Mental Health Waitlist - Youth

If you are in mental health distress or having a mental health emergency, please contact the Emergency Mental Health Line at 988 or BHR (1-800) 811-4760 or (314) 469-6644, the Suicide Prevention Line at 1 (888) 628-9454, or go to your nearest Emergency Room.
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Child's preferred language:*
Child's school and grade level*
Do you prefer in-person or virtual?*

in-personvirtualeither
What is your availability?

Morning (8:00 - 11:59 am)Afternoon (12:00 - 3:59 pm)Evening (4:00 - 5:59pm)
Should be Empty:

Emotional and Physical Wellness Department Interest Form