Emotional and Physical Wellness Department Interest Form

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

SelfReferring organization
Name*

First NameLast Name
Birthday

MonthDayYear
Date
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)Wellness groups (Spanish)Mental Health Individual Therapy. By selecting this option you will be added in our waiting list and you will be contacted as soon as a therapist has availability.
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: