Online Consultation Form
This online service is provided free of charge as a public benefit and all medical, emails and personal information received from clients are confidential. Response time is usually 24 hours or less. If you leave a phone number, we will make one attempt to contact you. If there is no answer, or you are not available, we will send you an e-mail to make further contact. The below request for information is gathered to help the placement specialist better determine an individual's needs and successfully match them with the best possible level of care available for them. Please fill out the confidential online assessment form to the best of your ability. All fields are not required, and remember - disclosing personal information is not required for assistance or a treatment referral, but if you do so, all personal information ( Name, emails, phone number) will be kept only for the sole purpose of communicating with you.