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Behavioral Health Contact Form
Please complete this form in its entirety. Our Behavioral Health Clinical Administrator will reach out to you via phone within 1 business day of receiving your submission based on your listed availability.
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* Indicates required question
Name
*
Your answer
Pronouns
*
They/Them
She/Her
He/Him
Ze/Hir
Other:
Required
Phone Number
*
Your answer
Email
Your answer
Best Days/Times to Call
*
Mondays: 10am-2pm
Mondays: 2pm-6pm
Tuesdays: 11am-3pm
Tuesdays: 3pm-7pm
Wednesdays: 10am-2pm
Wednesdays: 2pm-6pm
Thursdays: 9am-1pm
Thursdays: 1pm-5pm
Fridays: 9am-1pm
Fridays: 1pm-5pm
Required
What services are you interested in?
*
Individual Therapy
Group Therapy
Relationship/Couples Therapy
Family Therapy
Letter of Support for Surgery
Other:
Required
How did you hear about us?
*
Word of mouth (friends, family, etc.)
Referred from another agency (medical provider, social worker, etc.)
Referred by/participation with another COH department (Senior Services, HUB, etc.)
Social media
Flyers/advertisements
COH emails
Living/being around in the neighborhood/community
COH website
Previous Behavioral Health client
Internet searching (ex. Google)
In-person visit/walk-in
Other:
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