Request for Infant Early Childhood Mental Health Consultation

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Please fill out this form and a member of our team will contact you regarding the child. If you need immediate assistance or you are dealing with a mental health emergency, you can also contact 988 as a crisis lifeline or the Mental Health and Recovery Board warmline at 937-662-9080. Both are available 24/7 for assistance.

Name of Program/ Center / School /Agency

Name of person filling out the form

Role/Occupation of person filling out the form

Address

County

Phone Number

Email Address

Concerns/Reason for Referral

Parent/Guardian Concerns

How are the concerns being handled at the present time (what is working and what is not working)?

Are there other factors that may being affect the child’s health or development at the present time? If yes, please explain.

Is this request urgent?

Yes

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