Start Your Journey

Completing this form helps us connect you with the right care

Secure Intake Form

Your health and privacy are our top priorities. Please fill out the details below to begin your personalized connection to care and community support.

Health Intake Consultation

Please provide your information to help us prepare for your consultation.

First name

Last name

Email address

Phone

Birthday

Month

Day

Year

Address

Location Zip Code

Best Way To Contact (phone, text, email)

Phone

Text

Email

Do you have access to a phone or internet for telehealth? (Yes/No/Sometimes)

Yes

No

Sometimes

Are you currently or previously justice-involved? (Yes/No)

Yes

No

Briefly describe your current situation.

What feels most urgent to you right now?

Preferred Provider Type

Male

Female

No Preference

Schedule an appointment

April 2026

Week starting Sunday, April 12

Time zone: Coordinated Universal Time (UTC)Phone call

Thursday, Apr 16

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 1:00 PM

1:00 PM - 2:00 PM

Need help with the form?

support@secondchancehealth.org
(555) 012-3456