Pediatric mental and behavioral health services | Contact us

Use the form below to request a chat with a Craig Yabuki Mental Health Center access team member. A member of our access team will call you back within two business days to better understand your needs. If you need an appointment, they will help you find the right provider. They can also help you find resources. If you have any questions, call (414) 266-3339.

Note: If your child is experiencing an emergency of any kind, please call 911 or go straight to your closest emergency room.

Items in red or with a red asterisk* are required.

Patient's first name

Patient's last name

Patient's date of birth

Your first name

Your last name

Your relationship to child

Are you the child’s legal guardian? Yes No

A legal guardian is needed to complete the phone intake and schedule services. If intake is to be completed by someone who is not a legal guardian (i.e. foster parent), consent forms need to be completed and returned first. Consent forms may be requested at (414) 266-3339, option 2.

Phone number

Email address

Child's primary care doctor (name and phone number)

Service(s) of interest? Therapy Medication management/psychiatry Psychological evaluation

What are your current concerns?

Does your child have a Children’s Wisconsin Pediatrician? Yes No

Our Children’s Wisconsin pediatric clinics have primary care team members called Behavioral Health Consultants (BHCs). BHCs are licensed clinical providers who work together with the clinical care team to support the overall health and wellness of patients in primary care clinics. Appointments are generally available within a day or so of a request. If interested in learning more about this therapeutic options, please reach out to the pediatrician for scheduling.

Would you want to be contacted to schedule with a BHC? Yes No

A message will be sent to your child’s primary care physician’s office with a request to call for scheduling.

Is your child currently seeing a therapist? Yes No

Reason change is being requested?

Interested in: In person therapy Virtual therapy

Consider child’s age and ability to use technology independently, availability of private space for sessions to occur, reliable access to internet. Parents are to be available during sessions.

A referral from your child’s primary care physician is needed to access medication management services.

Has your child’s primary care physician submitted a referral for medication management/psychiatry services? Yes No

Who is currently prescribing the medication?

Reason for new provider request?

Please request a referral be placed for medication management services. You will be contacted once it is received. A phone intake will then be completed and options for care will be discussed.

A referral from your child’s primary care physician is needed for an evaluation (i.e. psychological, developmental). The referral is to include information on assessments that may have been done through primary care that led to the referral and should include specific questions the evaluation is being requested to assess.

Has your child’s primary care physician submitted a referral to request an evaluation? Yes No

Why are your current concerns which led to seeking an evaluatio

A referral for an evaluation is needed from your child’s primary care physician. There may be assessment tools and supports available from them to help provide direction for care. If it is determined an evaluation is needed, they may submit a referral to our program.

Please review the following statements and sign to indicate understanding and agreement with them.

- An Access Navigator will contact you after reviewing the inquiry form. While we aim to reach out to families within 24 hours of reviewing referrals, there are delays at times due to the volume of referrals. Your patience is appreciated.

- Access Navigator’s may be contacted at (414) 266-3339, Option 2.

- For children 14 and older, a teen intake also needs to be completed for therapy and medication management services. The intake is to confirm they are willing to participate in the service(s) being discussed and a safety screening is completed. These intakes may be done during separate calls but both are needed in order get on the waitlist/schedule an appointment.

- Wait times for an intake appointment vary based on various factors (i.e. location, provider, specialty).

- Appointments scheduled will be during first shift hours, Monday through Friday. Appointment verification notes may be provided for work and school.

Electronic signature

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Craig Yabuki Mental Health Center

Access team contact request

Please review the following statements and sign to indicate understanding and agreement with them.