Contact Request Form

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Do you have a question for us or are you interested in learning more about the services we offer?

Name *

Best email address to respond to questions/comments: *

Best day time phone number *

Can we leave a voice message if we are unable to reach you? *

Yes

Do you prefer we respond to your inquiry via email, phone or text message? *

Phone

Text

Required

Text Messaging: By selecting YES below to text messaging, you are giving us (Foothills Behavioral and Education Consultants) permission to use that provided cell phone number to respond to initial requests for information about our services and/or scheduling appointments. Our privacy policy is listed on our website page https://www.foothillsbehavioral.com/privacy
*

Yes, I request text and consent to this mode of communication

No, I do not wish to exchange information via text message as a mode of communication

Required

Town/City:

Optional: Additional information requests or comments below

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