Inquiry Form

Inquiry Form

Mental Health Therapy Request for Services
Please note, CCRC will do its best to respond to all inquiries within two (2) business days (M-F, not including holidays) for non-urgent requests. Please be advised, appointments are on a first come, first served basis.

DISCLAIMER:

CCRC does not provide 24-hour crisis services, sessions are by appointment only. If you have an urgent or emergent need for mental health assistance, please contact 9-1-1 or visit the nearest emergency room. You may also contact the following hotlines:

1-800- SUICIDE (1-800-784-2433)

1-800-273-TALK (1-800-273-8255)

Text HOME to 741741

Text/Call 988
Are you requesting services for yourself or on behalf of someone else?

SelfSomeone else
Name of Person to Receive Services (If requesting services for yourself, your name).*

First NameMiddle NameLast NameSuffix
Name of Person Requesting Services*

First NameLast NameSuffix
Date of Birth of Person to Receive Services*

MonthDayYear
Today's Date

MonthDayYear
Age of Person to Receive Services
Age in Months
Client Age
Is the person to receive services a child?

YesNo
Are you the legal guardian or parent?

YesNo
What is your relationship to the child?
Is the person to receive mental health services or anyone in their family currently receiving any other services from CCRC? (Note: Not a requirement)

YesNo
Which services does the person or their family currently receive from CCRC? Check all that apply.*

Head Start/Early Head StartHome VisitingSubsidized Child CareOther
What is your preferred language(s)? Check all that apply.*

EnglishSpanishOther
What is the BEST phone number to reach you?*
Format: (000) 000-0000.
What is the BEST email address to reach you?*
What is the BEST day(s) of the week to reach you? Check all that apply.

MondayTuesdayWednesdayThursdayFriday
What is the BEST time of day to call you? Check all that apply.

Morning (8 a.m. - 11 a.m.)Afternoon (12 p.m. - 3 p.m.)Evening (4 p.m. - 7 p.m.)
Please select the county the person to receive services resides in*
Should be Empty: