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.
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?
Mental Awareness Club for middle school students
Additional Kootenai County mental wellness resources
Other
Please verify that you are human
*
Submit
Should be Empty: