Mental Health Coalition Programs & Services Interest Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thanks for reaching out.

Please fill out this form to indicate which of our programs or services you are interested in and we'll respond shortly.

Our office is staffed Monday through Friday, 9am-4pm. All messages will be returned during these hours. We try to respond to all requests within two business days of receipt. Thanks for understanding!

*If you do not hear back from us in two business days, please check your spam/junk email folder

If you are experiencing a mental health crisis or are worried about being a harm to yourself or others, please call or text 988 or get to the nearest emergency room.

Name *

Email *

Phone Number *

Preferred Method of Communication *

Phone

Text

Required

City of Residence *

Program or Service of Interest (check all that apply) *

Help Paying for Counseling (Community Counseling Program)

Help Finding a Counselor (Referrals and Connection)

Help Finding Resources (Self Study)

Help with Crisis and Suicide Prevention

Get Training

Other

Required

Tell us a little bit about what you hope to get from this Program or Service. *

How did you find out about our services? For example: friend, family member, medical provider, newspaper article, social media post, etc *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Teton Valley Mental Health Coalition Inc.. Report Abuse

Forms