Brochure Request Form

Brochure Request Form
Thank you for your interest in partnering with 24/7 DCT! We are happy to provide brochures for your clinic to help inform patients about our mental and behavioral health services, including counseling and ABA therapy for children.

Please fill out the form below to request brochures for your clinic. We will process your request promptly and ship the materials to your practice address.
Requestor Information:
Name*

Your NameYour Title
Practice Name*
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Email Address*
example@example.com
Brochure Request
Brochure Request Type

First TimeRefill
Language Preference (Select one or both)*

EnglishSpanishBoth
Do you need a brochure holder?*

YesNo
Lunch & Learn Request
Would you like to schedule a lunch and learn?*

YesNo
Prospective Lunch Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
No of People Attending*
Dietary Preferences (You can choose multiple options)*

Regular (No Restrictions)KosherHalalVeganVegetarian
Virtual Meeting Request

This is to schedule a virtual meeting with our practice director to learn more about organization and answer any questions you may have.
Would you like to set up virtual meeting?*

YesNot at this time
Virtual Meeting Date/Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Additional Requests or Comments (Optional):
Once your request is submitted, our team will process it, and you will receive your brochures soon! If you have any questions, please contact

Geeta Mhaske at gmhaske@247dct.org.

Thank you for partnering with 24/7 DCT to support mental and behavioral health in your community!

*By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging reply HELP for more information and then message frequency may vary.
Should be Empty:

Brochure Request Form

Requestor Information:

Brochure Request

Lunch & Learn Request

Virtual Meeting Request