Request for Telehealth Services

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  • If this is an emergency, please call 911, or, if able to do so safely, get yourself to the Emergency Room of your nearest hospital.

  • Optionally, you may wish to call an appropriate local Crisis Line.

  • This request for telehealth services is not intended to be used as an emergency response to a mental health or other crisis.

Telehealth Service Request

Your Email will ONLY be used if we need to email you something you agree in advance to receive. We do NOT share your email address with anyone else.
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