Appointment Request Form (Mental Health) First Name*Last Name*Date of Birth*Cell Phone Number*Email*Race*WhiteBlackAsian/PIAm Indian/ Alaskan2 or more RacesOtherEthnicity*HispanicNon-HispanicWhen was the last time you saw a mental health professional?Please describe in brief the reason you would like to book this appointment*Submit Error occured. Please confirm your data and submit again: