Kroc Support Services Interest Form
Thank you for reaching out! Your responses will help us better understand your needs and provide the most effective support.
Personal Information
Full Name
*
First Name
Last Name
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Demographic Information
Gender
*
Please Select
Male
Female
Nonbinary
Prefer Not To Say
Which race or ethnicity best describes you?
*
American Indian or Alaskan Native
Asian / Pacific Islander
Hispanic
White / Caucasion
Multiple Ethnicity
Prefer Not To Say
Other
Languages spoken at home:
*
English, Spanish, French, Japanese, etc
Household Information
Household Size:
*
Please Select
1
2
3
4
5
6
7
8
9
10+
Number of children under the age of 18:
*
Please Select
0
1
2
3
4
5
6
7
8
9
10+
Service Interest
Which service are you interested in?
*
Therapy
Education
Community Resources
Other
If choosing therapy, how would you like expenses covered?
*
Self-Pay
Requesting Financial Assistance
Not Applicable
Insurance (Please Specify)
Communication Preferences
Preferred method of communication:
*
Phone
Email
Text
Best times to contact:
*
Morning (7am–11am)
Afternoon (12pm–4pm)
Evening (5pm–7pm)
Other
Specific Concerns
Briefly describe why you're seeking support and any specific concerns you have:
*
Goals/Expectations from Services
Please share your goals or expectations from these support services:
*
Additional Interests
Is there anything else you're interested in learning more about?
Additional Kootenai County mental wellness resources
Other
Please verify that you are human
*
Submit
Should be Empty: