Mental Health Continuation Request Form
Request continuation of mental health-related services by providing the information below.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Other
Service(s) for Continuation
*
Individual Counseling
Group Therapy
Medication Management
Crisis Support
Other
Current Provider Name
Briefly describe your current treatment or support context
*
Reason for Continuation Request
*
How urgent is your request?
*
Please Select
Routine
Needed within 2 weeks
Needed within 1 week
Immediate
Additional Notes or Supporting Information
Submit Request
Should be Empty: