Interest Form
Thank you for your interest in the University of New Mexico Department of Psychology Clinic. Please provide your name, contact information, and reason for seeking treatment in the secure form below. Someone will be in contact with you within a few days. Please note: if you need immediate help, if you or someone you know is thinking about suicide, or are experiencing crisis, please contact AGORA Crisis Center at 505-277-3013, 988, or 911.
Heading
Name
First Name
Last Name
If you're contacting us on behalf of another person (child, parent, spouse, etc.), please indicate their name and your relationship to them below.
Email
example@example.com
Phone Number
Please enter a valid phone number.
What brings you to the clinic?
Anxiety and/or panic
Depression
Alcohol Use
Assessment
Therapy for youth (age 6-17)
Gambling Use
Eating Disorder
Other
If "other" please provide a brief description.
Submit
Should be Empty: