REQUEST SERVICES

Your Next Step Starts Here.

Tell us how we can reach you and which services you're interested in. A member of our team will follow up with you about the next steps.

GETTING STARTED

We're Here to Help You Get Connected.

Reaching out is the first step. You don't need to know exactly which service you need before contacting us.

Complete the short request below with your basic contact information and the type of support you're interested in. Our team can help determine the appropriate next steps.

Please don't include sensitive medical information.

This form is for initial contact only. Please do not submit diagnoses, medications, Social Security numbers, insurance identification numbers, or detailed medical or mental health information.

SERVICE REQUEST

Tell Us How to Reach You.

Fields marked with * are required.

About This Request

Who are you requesting services for? *

Myself My Child Family Member Someone Else

Contact Information

First Name *

Last Name *

Phone Number *

Email Address

Required if you prefer to be contacted by email.

Preferred Language *

Preferred Contact Method

Best Time to Contact

Services

What services are you interested in? *

Select all that apply. It's okay if you're not sure.

✓ Counseling Therapeutic support for emotional and behavioral wellness. ✓ Case Management Support navigating resources, services, and everyday needs. ✓ I'm Not Sure Our team can help you determine where to start.

Person Needing Services

Age Group

Please don't include sensitive medical information.

This request is only for initial contact. Our team will gather any additional information that may be needed after contacting you.

I understand that submitting this form does not establish a provider-client relationship and should not be used for emergencies or urgent mental health needs.

Our team will contact you regarding the next steps.

WHAT HAPPENS NEXT?

After You Reach Out

Send Your Request

Provide your basic contact information and services of interest.

We Contact You

A member of the Serenity team will follow up with you.

Determine Next Steps

We'll help you understand what information is needed to move forward.

Need Immediate Help?

This form is not monitored for emergencies. If you are experiencing an immediate emergency, call 911 or go to the nearest emergency department.