Lets Connect You To Care!

You will be contacted within 2-business days.

This is only for non-emergency related services. If you are experiencing any physical or mental health emergency, please dial 9-1-1 or head to the nearest hospital
If you are referring a patient from a health care practice, please do not submit this form and instead contact the desired clinic directly. 
Patient or Parent/Guardian
If available
Is this referral coming from a school site or school district?
*Teen Wellness offers confidential family planning & contraceptive counseling, free for those who qualify (Ages: 12+)
Only if applicable
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