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Intake Form

The Ava Michelle Project uses this information to help connect them with appropriate mental health care options.

Support Intake Form

Please fill out this form to help us connect you with the right care. Your information is kept confidential.

Age Range
Ethnicity
Preferred Contact Method
Email
Phone Call
Text Message
Type of Support Seeking

Select all that apply to your current situation.

Urgency Level
Low (Within a few weeks)
Medium (Within a few days)
High (Immediate need)
Are you in immediate danger?
Yes
No

If yes, please call 988 or 911 immediately.

Please share any additional details that will help us assist you.

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