Mental Health Client Contact Form

Mental Health Contact Request Form

Fill out the form below and one of our therapists will be in touch. *PLEASE NOTE- if you are experiencing a mental health emergency, call the Mobile Crisis Outreach Team (MCOT) 1-800-273-8255, or 911
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address*
example@example.com
Have you accessed services at UAF before?*

YesNo
Please briefly tell us why you are looking for counseling services. *These answers are confidential.
Thank you for reaching out!

One of our therapists will be in contact within 48 hours.
Should be Empty:

Mental Health Contact Request Form