Emotional and Physical Wellness Department Interest Form

Emotional and Physical Wellness Department Interest Form
Hi! Please fill out this form and one of our staff will contact you in 5-7 business days to speak further. Additionally, for the safety and health of everyone, we ask you wear a mask when attending any classes and/or appointments.
Who is filling out this form?*

SelfReferring organization
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Preferred language:*

SpanishEnglishMandarin ChineseOther
Email
example@example.com
How did you hear about our programs?*
How can we communicate with you?*

Call meText me
Is it ok to leave a voicemail?*

YesNo
Below is a list of services we provide. Please check all of the services that you are interested in.*

Support groups (English)Support groups (Spanish)Mental health evaluations (only pick if you are a lawyer)
Please note: our youth and adult therapy waitlists are closed at the moment.

If the services you are looking for is not listed, ours may not be the program you are looking for. If you have general needs, please feel free to contact our Community Care Liaison at 314-260-6396.

For immediate assistance with:

* Filling out food stamps application, please call 1-855-373-4636

* Filling out medical applications, please call 1-855-373-9994 (to apply).
Should be Empty: