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KidsPeace Assistance Form

Please complete this form to request help through our world class continuum of KidsPeace Programs and Services or call 888-KP-HELPS.
You will be able to expand upon the information you provide here when a KidsPeace Associate contacts you.

Click here to learn more about the KidsPeace Mental Health Network Lehigh Valley

!!! IMPORTANT REMINDER !!!
If you are experiencing an emergency, please contact 911 emergency services immediately.

Contact Information

* First Name:    MI:    * Last Name:
* Phone Number:   Cell Number:
 Email Address:
 Verify Email Address:
* Best way to be contacted: 
* Mailing Address:
                    (line 2)
                    (line 3) 
* City:     * State:     * Zip Code:

Patient Information (the person requiring services)

* First Name:     MI:    * Last Name:

* Date of Birth:  [None] Select a Date Delete the Date (click first icon to enter date - click second icon to remove)

* Gender:                                                     * Relationship to You:      

* Level of Care Needed (if known):


*Reason for Assistance:

   Please briefly describe (in 132 characters or less) what led you to seek assistance from KidsPeace.
   Remember, you will be able to expand on the information you provide here when a KidsPeace Associate contacts you.