Thank you for your interest in notMYkid's services. Our programs are dedicated to supporting youth mental health and wellness, inspiring positive life choices.
Please fill out this brief questionnaire so we can identify how to best meet your needs and one of our team members will be in touch during normal business hours.
If you are reaching out for assistance with our early intervention program, Project REWIND, there is a program link on our website to register.
*An intake is required for all clinical groups & services. A staff member will reach out to schedule an intake after form submission.
Client's Name (First, Last)
Preferred Name (if applicable)
Date of Birth
Parent/guardian Date of Birth
Cell Phone Number
Address of parent/guardian (if different from client)
Permission to text?
Please list insurance plan
Subscriber name (policy holder)
Subscriber DOB (policy holder)
Group Number ID
Reason for referral/presenting problem:
I am interested in the following services (please select all that apply):
Group Counseling/ Life-skills group
[i]nspired Peer Program: Individual & Groups available
Additional Education & Support Services
Middle School & High School IOP (New January 2023!)
Mohave County [i]nspired Group
Have you ever participated in any notMYkid programs? If yes, please explain.
Are you willing to enroll in remote, telehealth services for treatment?
How did you hear about our program?