The Diversity Center (TDC) Mental Health Service Request
Please fill out this form if you are interested in mental health counseling and case management services with The Diversity Center. You may also fill out this form on behalf of the person requesting mental health services.

The Mental Health Program is on summer break from June through August. You may fill out the form to be added to the wait list, when services resume in September.

Feel free to reach out to us for more information, or to ask about services:
Phone: 831-322-4870 /  E-mail: mhservices@diversitycenter.org

At this time, this form is only available in English. For support in a different language please call or email us.

Free counseling services: The Diversity Center can offer these services at no charge because of securing grants and receiving generous donations for mental health services. 

If you are in crisis, or need someone to talk to right away: Call 9-8-8 for the Suicide and Crisis Lifeline (24/7); Call The Trevor Project, an LGBTQ+ confidential free hotline, at 866-488-7386 (24/7); Call Trans Lifeline at 877-565-8860 to speak with a counselor (24/7). You can also call the Crisis Stabilization Program at 831-600-2800. For mental health emergencies, please call 9-1-1 or go to your local emergency room for immediate assistance.

We look forward to connecting with you!

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Language Needs
Do you prefer to communicate in a different language than English?
 *
If you answered "Yes," in what language do you prefer to communicate?
Who is completing this form? (Check all that apply.)
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Full Name of Individual who is requesting services.
(Please provide the current First and Last name)
 *
Full Name of Individual who would receive services.
(Please provide the current First and Last name of person). 
 *
Individual's Pronouns? (Individual who would receive services)
(e.g. they/them/theirs, she/her/hers, he/him/his, they/she/any, etc.)
 *
Date of Birth of individual who would receive services?
(Enter MM/DD/YYYY)
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MM
/
DD
/
YYYY
Age of the individual who would receive services. *
Zip code for the individual who would receive services.
(Please enter the 5-digit number + optional.)
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Best phone number for follow up on this request?
(xxx-xxx-xxxx)
 *
Email Address? *
Preferred way of contact? *
When calling or emailing, can we say we are from The Diversity Center in a message? *
If it's not okay to identify TDC in the message, are there special contact instructions? Or Enter "N/A" *
What are some best days/times for a clinician to contact requester to follow up? 
(Please provide multiple days and times. Note: We are not open on the weekends or after 7pm.)
 *
Caregiver/Parent's Name (Enter N/A if not applicable).  *
Current living situation?
(Describe where and with whom you live, as well as housing type- own, rent, houseless, multi-family sharing, roommates, etc.)
 *
Do you have Medi-Cal AND live in Santa Cruz County? *
What Diversity Center Program(s) are you involved in or interested in (e.g. youth, trans, senior, queer yoga, book club, general events, etc.) *
If you go to school, what school do you go to? Enter N/A if none. *
What mental health services are you interested in receiving? *
Required
Please tell us why you are interested in counseling services. *
In-Person Service Availability?
(Is individual physically able to attend in-person services?)
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Please provide more information if you marked "No, Maybe or Other" to the above question.
Telehealth Service Availability?
(Is individual able to receive services via telehealth through any video & audio conference software?)
 *
Please provide more information if you marked "No or Other" to the above question.
Anything else you'd like to share or ask regarding your inquiry?
(Comments, questions, additional information)
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