LAHC Outpatient Inquiry Form

LAHC Outpatient Inquiry Form
Thank you for reaching out to LAHC - Leaders Advancing & Helping Communities regarding outpatient services. Submission of this inquiry does not guarantee services and should not be used for urgent matters. If you are experiencing a mental health or medical emergency, please call 911 or go to your nearest emergency department.
Name

First NameLast Name
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Who are you inquiring about services for?
Is this inquiry for a minor child?
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Brief reason for seeking services
How did you hear about LAHC?
Questions or need assistance?

If you have any questions about services or need assistance completing this referral form, please contact the LAHC office at 313-846-8480.
Should be Empty: