Request an Appointment for Mental Health

Complete the form below, and a member of our team will contact you shortly to schedule your appointment. All information is confidential.

Your Name(Required)

First Last

Address(Required)

Phone(Required)

Who is this appointment for?

Myself

My Child

Other

Preferred Appointment Location

In-Person

Virtual

No Preference

What kind of support are you looking for? (Check all that apply)

Anxiety or Stress

Depression

Grief or Loss

Trauma or PTSD

Dissociative Identity Disorder (DID)

Child/Adolescent Behavioral Issues

Not Sure / I just know I need help

Choose a service. (Check all that apply)

Therapy

Medication Management

Substance Use

Behavioral Health Intervention Services (BHIS)

Community Support Services (CSS)

Parent-Child Interaction Therapy (PCIT)

Couples Counseling

Family Therapy

Not Sure / I just know I need help

Do you need help with paying for services?

Yes, please contact me about financial assistance

No, I do not need financial assistance

I’m not sure yet

Anything else you’d like us to know?

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Burgess Mental Health Appointment Request Form