Consultation Request Form
Thank you for taking the time to complete this form as thoroughly as possible to receive a 15 minute FREE consultation with Dr. TJ Jackson.

IF THIS IS AN EMERGENCY PLEASE STOP AND DIAL 911 FOR IMMEDIATE HELP.

Additional crisis care assistance can be received at:

Suicide PreventionLifeline 1-800-273-TALK (8255)
National Hopeline Network 1-800-442-HOPE (4673)
MHMR Care Call Center 1-817-335-3022
To Report Abuse/Neglect 1-800-252-5400
Crisis Hotline Text "HELP" to 741741
Texas Youth Hotline 1-800-989-6884 or text 512-872-5777

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