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If are thinking of hurting yourself or someone else, we want to help you right away! Please call us:

Kentucky: 502.589.4313

Florida: 941.782.4617

Illinois: 855.985.0911

Indiana: 800.832.5442

Tennessee: 800.681.7444

National Suicide Prevention Lifeline: 800.273.8255
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Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State Zip Code
Best time of Day to Contact
Reason for Visit
Do you need care urgently?
- Yes
- No
Get Help Now »

If are thinking of hurting yourself or someone else, we want to help you right away! Please call us:

Kentucky: 502.589.4313

Florida: 941.782.4617

Illinois: 855.985.0911

Indiana: 800.832.5442

Tennessee: 800.681.7444

National Suicide Prevention Lifeline: 800.273.8255
Insurance Provider
- Commercial
- Medicaid
- Medicare
- I don’t have insurance
- I plan to pay out of pocket
Your privacy is deeply important to us. This form is secure so that only our call center staff will see the information provided, and they will only use it to schedule your appointment. Click here to learn more about our privacy practices.
Phone
This field is for validation purposes and should be left unchanged.