Mental Health Provider/Organization/Resource Information Form
Help us add you to our list of local providers/resources.
Name
First Name
Last Name
Name of Facility/Practice/Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What type of services does your facility/practice provide?
Mental Health Services
Family Services
Counseling/Psychotherapy
Medication Management
Substance Use Services
Animal Therapy
Other
Does your facility/practice serve Adults, Youth, or Both?
Please Select
Adults
Youth
Both
If Other, please explain what services you provide.
Does your facility/practice accept major insurances?
Yes
No
Some
Does your facility/practice accept Medicaid?
Would you like to be added to our list of local mental health service providers that will be made available to our community and listed on our website?
Yes
No
Are you interested in setting up a booth/table at our future mental health/suicide awareness events?
Yes
No
Is there anything else you would like us to know about your practice/facility and the services you provide?
Submit
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