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?
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What is your child's name?
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How old is your child?
What is your phone number?
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What is your email address?
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What is your zip code?
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What is the best way to reach you?
Where is your child now?
Please select all that apply to your child:
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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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