My child needs help!
Please fill out the below questionnaire and we will get back to you within 24 hours for assistance.

IF THIS IS AN EMERGENCY, PLEASE CALL 9-1-1.

What is your name? *
Your answer
What is your child's name? *
Your answer
How old is your child? *
What is your phone number? *
Your answer
What is your email address? *
Your answer
What is your zip code? *
Your answer
What is the best way to reach you? *
Where is your child now? *
Please select all that apply to your child: *
Required
Is your child taking any prescribed medications? *
What medications are prescribed to your child? *
If none, please type N/A, or indicate if there are any prescription medications that are being abused without a prescription.
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How did you hear about us? *
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