Name

*Age (indicate over or under 21)

Email (please provide if you would like a personal reply)

*Choose the best description of your occupation as it relates to our system of care:
Consumer of Mental Health Services (Youth) Parent of Child Receiving or Needing Mental Health Services Children’s Division Employee Division of Youth Services Employee Education/School Employee or Administrator Juvenile Justice Officer, Judge, or other Employee Law Enforcement Officer or Employee Mental Health Service Provider Regional Center/MRDD Service Provider State or Federal Representative, Senator, or Assistant Business Owner Physician (other than Mental Health) Religious or Faith-Based Leader Not-for-Profit Organization Social Organization Other (please specify)

Have you or your children ever been enrolled in services funded through Show-Me Kids? (indicate yes, no, or unsure.)
Yes No Unsure

Is this your first time using the SMK website? (indicate yes or no)
Yes No

Do you live in one of these MO counties:
Barry Christian Greene Lawrence Stone Taney Other Missouri County I do not live in Missouri

Have you seen a Show-Me Kids billboard in the Springfield or Southwest Missouri area?
Yes No

*Please rate the Show-Me Kids website.

Questions or comments about the Show-Me Kids website or system of care:
(500 character maximum)

Please note: This form will be sent to a database which is checked periodically. We cannot respond to comments or questions regarding clinical or personal information. We cannot accept referrals online. Please do not include any specific or private information about yourself or your child.

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