Emotional and Physical Wellness Interest Form

This form is no longer active. Este formulario ya no está activo.
Please complete our new interest form here:

Por favor complete nuestro nuevo formulario de interés aquí:

https://form.jotform.com/233196389407163
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 day to speak further. Additionally, for the safety and health of everyone we ask you wear mask when attending any classes and/or appointments.
Who is filling out this form?*

SelfReferring organization
Name of Referring Organization:*
Name of Staff Member making referral:

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

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

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

Call meText meYou can call or text
Best day(s) to call/text:

MondayTuesdayWednesdayThursdayFriday
What time of day is it best to call?

9 AM -12 PM1 PM -4 PMOther
Is it ok to leave a voicemail?*

YesNo
Emotional Wellness Interest Form
Below is a list of services we provide, please check all of the services you are interested in:

PsycheducationTherapy GroupsSupport Groups (spanish)Support group (english)Individual TherapyMental Health Evaluation (only pick if you are a lawyer)
If the service 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 Liason at 314-329-7147.

For immidiate assistance with:
- Filling out food stamps application please call: 855-373-4636
- Filling out medicaid applications please call: 1-855-373-9994 (to apply)
Are you currently pregnant?*

YesNo
Estimated Due Date (MM/DD/YYYY)
How many children do you have? *
Please list their ages (separate with a comma):*
Youth Mental Health Interest Form

Currently Services are for youth in Kindergarten through Senior year of high school
Below is a list of services we provide, please check all of the services you are interested in:

General informationIndividual Youth Therapy
If the service you are looking for is not listed, Youth Mental Health may not be the program you are looking for.
Child's Full Name *

First NameLast Name
Child's Age:*
in years
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Relationship to child: *
Ex. Mother, grandfather, etc.
Physical Wellness Interest Form
Below is a list of services we provide, please check all the ones you are interested in:

Nutrition ClassesExercise ClassesOne on One CoachingHealth Education Classes
Please provide us with any other information you would like us to know before contacting you.
Should be Empty:

This form is no longer active. Este formulario ya no está activo.

Emotional and Physical Wellness Department Interest Form

Emotional Wellness Interest Form

Youth Mental Health Interest Form

Physical Wellness Interest Form