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Rockford Barbell
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The Winnebago County Community Mental Health Board is a vital partner and resource for Rockford Barbell as a funded mental health service provider.
Parent Request for Additional Services Form
Parent/Guardian First name
*
Parent/Guardian Last name
*
Parent/Guardian Email
*
Parent/Guardian Phone
*
Name of Child
*
Which program is your child in? *Child must be currently enrolled in a program to receive additional services.
*
What type of services are you interested in? Select all that apply.
*
Individual Counseling
School support
Resources/community support
Family Counseling
Other
Best time of day to be contacted?
*
Morning
Afternoon
Evening
Submit
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