Contact the ICMH-Clinic

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

By submitting this form, you consent to our collection of your contact information solely for the purpose of responding to your inquiry about services. We do not collect any educational records or health information through this form. Your data will be stored securely and will not be shared or sold.

Safety Disclaimer: If you are experiencing a health or mental health emergency, including suicidal thoughts or feelings, please immediately call 911 or 988, or go to your nearest emergency room.

The ICMH Clinic is unable to provide emergency or crisis services. Information entered into this form is typically reviewed within five business days.

Name (first and last) *

Phone number *

Email *

Preferred contact method (please select all that apply) *

Phone call

No preference

Required

Are you interested in (please select all that apply) *

Therapy services for myself.

Assessment services for myself.

Therapy services for my child (under age 18).

Assessment services for my child (under age 18).

I am not sure what services I need.

I am a service provider interested in obtaining more information about the ICMH Clinic.

Required

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of University of Delaware.