Emotional and Physical Wellness Department Interest Form

Emotional and Physical Wellness Department Interest Form
Who is filling out this form?
Name

First NameLast Name
Birthday

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred language:

Other
Email
example@example.com
How did you hear about our programs?
How can we communicate with you?
Is it ok to leave a voicemail?
Below are the services we offer. Please indicate your interest by selecting Yes or No for each option.
Are you interested in joining support groups (English)?
Are you interested in joining wellness groups (Spanish)?
Are you interested in individual mental health therapy?
Important
If you select “Yes,” you will be placed on a waiting list. We will contact you when a therapist becomes available.
If you currently have health insurance (Medicaid, Medicare, Anthem Blue Cross Blue Shield, Ambetter, Medica, Cigna, UnitedHealthcare, etc.), please type the company name below. You can still receive services if you do not have insurance.
If the services you are looking for are 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:

*Menthal health Crisis, PLEASE CALL 988

* 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: