I Need Help Request Form
This form is confidential, and will be sent only to members of the Behavioral Health Department to provide support for the respondent. All information is to be treated as confidential, including the fact that the respondent receives (or previously received) services through this office. The privacy and confidentiality of respondents are protected under the Ethics Codes of the mental health professions, state laws and regulations, and federal HIPAA Regulations. No respondent information may be disclosed without the explicit informed consent of the respondent and authorization by his/her clinician.
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Name *
How do we contact you? *
What can we help you with? *
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