Thank you for your interest in notMYkid's services. Our programs are dedicated to supporting youth mental health and well-being through an array of prevention and behavioral health programs.
Please fill out this brief questionnaire so we can identify how to best meet your needs and one of our team members will be in touch during normal business hours, Mon-Fri 9AM-5PM.
An intake is required for all groups & services. A staff member will reach out to schedule an intake after form submission.
*If you are reaching out to enroll in our early intervention program Project REWIND, please complete this form
CLICK HERE
*Client means person needing services.
Client Name (First and Last)
Client Date of Birth
Client Age
School Attending
Grade
Client email (if 18 or over)
Client Cell Phone Number (if 18 or over)
By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.
Parent/Guardian Cell Phone Number
City, State
Parent/Guardian Email
Parent/Guardian Name
By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.
Name of insurance provider
I am interested in the following services (please select all that apply):
Clinical Assessment (90 mins)
Individual Counseling (60 mins)
Family Counseling (60 mins)
Group Counseling (60 mins)
Intensive Outpatient Treatment (9 hrs. per week)
Mohave County Outpatient Programs
Reason for referral/presenting problem:
Have you ever participated in any notMYkid programs? If yes, please explain.
Are you willing to enroll in remote, telehealth services for treatment?
Yes
No
How did you hear about our program?
If you need help filling out this form or have additional questions, please contact our office at (602) 652-0163. You can also schedule a call at
here
.
Contact Information