If you need immediate assistance, do not use this form. Please call 911, go to your local emergency room, or call the Mental Health Hotline at 988.
Note: By emailing us, you are giving your consent for a response by email, understanding that email may not be encrypted and even if encrypted, email poses security risks that threaten confidentiality (i.e., other people reading your messages, hacking and email pirating, lost or stolen devices). If you would prefer a response in another format (telephone, voice mail, FAX, or postal service), please indicate your preference by contacting us by any of these other methods.
What are you contacting us about?
What is the member's full legal name? Please include your name if you are not a member.
Your answer
What is the member's date of birth?
MM
/
DD
/
YYYY
If you would like a reply by email, what is your email address?
Your answer
If you would like a reply by phone, what is your phone number?
Your answer
If you would like a reply by mail, what is your mailing address?
Your answer
Message
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Better Care Center. Report Abuse