Thank you for your interest in notMYkid's outpatient treatment program. We are now offering mental health and substance use disorder treatment services for youth and families.

Services available:

Child and Family Counseling (individual & groups available)

Peer support and group coaching for teens

Case management services

Please fill out this brief questionnaire and one of our team members will be in touch by the next business day.

Client's Name (First, Last)

Preferred Name (if applicable)

Date of Birth

Age

Mailing Address

Parent/guardian Name

Cell Phone Number

School Attending

Grade

Address of parent/guardian (if different from client)

Permission to text?

YesNo

Insurance Information

Please list insurance plan

Reason for referral/presenting problem:

How did you hear about our services?

TLC PediatricsMohave Accelerated Learning CenterOther

If other, please explain.

Contact Information