Request for Services

If you reside in Wood County and your child is experiencing a crisis, please call us directly at 419.352.7588. For those outside of Wood County, click here for crisis providers in your area.

Please note, while we don’t accept direct referrals from parents/guardians for specific programs, every child will receive a comprehensive mental health assessment prior to receiving services. This process is designed to develop a dianostic forumulation and identify the child’s relevant needs. The mental health assessment forms the basis for all subsequent treatment planning.

For Prevention Services, please complete the referral form here.

Please complete the following form or call 419.352.7588 to request services.

Who is completing request?

Self

Parent/Guardian

Other

Parent/Guardian/Other Name

First Name

Last Name

Client Name

First Name

Last Name

Client Preferred Name

First Name

Last Name

City

Phone

(###)

###

####

Email

Reason(s) for Referral?