Request for Services Form This form is only monitored Monday - Friday during regular business hours (9:00am – 5:00pm CST). If you or a loved one are experiencing a mental health emergency, please dial 988 or 911. Your Name(Required) First Last Who is seeking services?(Required) I am seeking services for myself I am referring someone else Name of the Person You're Referring(Required) First Last What Is Your Relationship to the Person Being Referred?(Required)Family MemberFriendHealthcare ProviderCase ManagerEmployerOtherOther (Please Describe Your Relationship)(Required)The Person I Am Referring Is a: (Please check all that apply)(Required) Service Member Veteran Military Family Member First Responder First Responder Family Member None of the Above Your Contact InformationEmail Address(Required) Phone(Required)Preferred Contact Method(Required)No preferencePhoneEmailContact Information for Person Being ReferredTheir Email Address(Required) Their Phone Number(Required)Their Preferred Contact Method (if known)(Required)No preferencePhoneEmailAdditional InformationPlease check any that apply to you:(Required) I am a Service Member I am a Veteran I am a Military Family Member I am a First Responder I am a First Responder Family Member None of the Above Where Are the Services Needed?(Required)-- Please Choose --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOTHEROther (Please List Where Services Are Needed)(Required)What Services Are Needed?(Required) Individual Counseling Couples Counseling Family Counseling Group Counseling Substance Use Support Suicide Prevention and Crisis Support I'm Not Sure Are there any specific concerns, circumstances, or additional details that would help us provide support that you would like to share?Current Gary Sinise Foundation Program Involvement R.I.S.E Snowball Express Other None, but interested in learning more Other (Please list Gary Sinise Foundation Involvement)(Required)
