Request for Services

If you reside in Wood County and your child is experiencing a crisis, please call us directly at 419-352-7588. For those outside of Wood County, find your local provider by calling 1-888-418-MRSS (6777).

To request Prevention Services, please visit our Prevention Services page.

Please complete the following form or call 419-352-7588 to request services.

Please note, while we don’t accept direct referrals from parents/guardians for specific programs, every child will receive a comprehensive mental health assessment prior to receiving services. This process is designed to develop a diagnostic formulation and identify the child’s relevant needs. The mental health assessment forms the basis for all subsequent treatment planning.

Who is completing request?

Self

Parent/Guardian

Other

Parent/Guardian/Other Name

First Name

Last Name

Client Name

First Name

Last Name

Client Preferred Name

First Name

Last Name

City

Phone

(###)

###

####

Email

Reason(s) for Referral?