Forms

January 11, 2023

Financial Assistance Application and Instructions

October 20, 2021

Financial Assistance Sliding Fee Scale

October 20, 2021

Financial Assistance Plain Language Summary

October 20, 2021

Request to Correct or Amend Personal Health Information

Crisis Assistance

If you are having a medical emergency, please dial 911.

If you’re in an emergency, or need to reach us right away, our helpline is available 24/7. If you experience a crisis or have an urgent matter, dial (800) 433-7291. Callers can remain anonymous and receive support from trained Crisis Line technicians who have access to the resources and information they so desperately need during the most vulnerable times of their lives.

Forms

PSY Intake

NCS Intake

Referral Form

Financial Assistance Application and Instructions

Financial Assistance Sliding Fee Scale

Financial Assistance Plain Language Summary

Financial Assistance Policy

Fee Reduction Request Form

Consumer Concern Form

Request to Correct or Amend Personal Health Information

Crisis Assistance