Merrimack Valley Youth Mental Health Resource Guide

Please complete the application below to have your agency included in the Merrimack Valley Youth Mental Health Resource Guide. All submissions will be reviewed by the committee before inclusion. If your agency offers multiple youth mental health or behavioral health programs, please submit a separate application for each program.

"*" indicates required fields

Organization Name*

Department Name*

Address (Please include street name, building # (if applicable), town/city, state, and zip code)*

Website (if applicable)

Contact Information

Please provide the information for the point person of contact at your agency.

Contact Person*

Contact Email*

Contact Number*

Agency Description

Service Category*

Please choose one.

Agency Description*

Describe the services your organization provides in 250 words. Please include the following information: catchment area, population served, detailed description of services provided, and a description of how to access services.

Agency Logo

Accepted file types: jpg, png, Max. file size: 128 MB.

Please provide your agency's logo (if applicable).