REQUEST FOR SUPPORT AND GUIDANCE FROM MEHAR

Disclaimer: Please be advised that the submission of this request form implies your consent to MEHAR and/or designated staff to contact you for further assistance and follow-up. If you are submitting this form on behalf of someone, we will need consent from the concerned individual prior to providing assistance.

SECTION A: SELF REFERRAL

Please fill out this section if you are requesting support and guidance for yourself.

A-1. Contact Information
First Name
Middle Name
Last Name

Please follow the format ###-###-#### for contact numbers

Address
A-2. Referral Information
A-3. Reasons For Contacting MEHAR

Please check the box on the applicable reason 

Who is in need of services?

If you are submitting this form on behalf of another person, please indicate your relationship to them:

What brings you to seek MEHAR’s services? (Please check all that apply):

A-4. Duration of Concerns
A-5. Previous Treatment
A-6. Consent & Confidentiality

I understand that the information provided will be kept confidential in accordance with applicable laws. I consent to receiving mental health services from this organization.