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YSD - Appointment/ Information Request

Appointment/Information Request

**If this is an emergency, call 911. To speak with someone for immediate mental health support, please call 988 or 211.
Requests for appointments made via internet are only checked during business hours.**

Parent First Name:

Parent Last Name:

Child First Name:

Childs Last Name:

Child's Age:

Email Address: *This question is required. This question requires a valid email address.

Phone Number:

Zip/Postal Code:

Country:

Service Requested: *This question is required.

Residential (ages 11-16) *Youth stay Mon-Fri at the Center*
Parent Education
Parent-Child Interaction Therapy (ages 2-7)
Family Therapy
Individual Therapy (ages 18-22)

Language Preference:

Please enter an 'other' value for this selection.

By checking ‘yes’ to this box, I consent to receive information, registration forms, and appointment reminders about Youth Services programs via email and/or voicemail.

E-mail Disclaimer:

Your email will not be sold or used for mailing lists except as indicated above for the Youth Services Department (YSD) services. Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

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