Request for Information

Emergency Assistance

If this is an emergency, call 911!

Hawaii CARES provides a team of professionals 24/7 to help in a mental health crisis.
Oahu: 832-3100
Other islands: 1-800-753-6879

Request for Information

All requests are kept secure and confidential. We aim to respond within two business days, if not sooner.

Questions with an asterisk (*) are required.

First name

Last name

Email address

Contact Phone number

Preferred method of contact For privacy, our return emails or voicemails do not specify details, such as the name of the individual who would attend the appointment.

Email Phone

Seeking services

TEST ASSESSMENT (EVALUATION) SERVICES Please check as many as needed.

ADHD

Autism

Learning Difficulty

Neurocognitive (includes Alzheimer's, Dementia)

PTSD

Traumatic Brian Injury (includes Concussion)

Surgery

Other

Concerns

Please describe what you are looking for, and who this is for if not yourself. If there's anything else that you would like us to know prior to scheduling an appointment, please include it here.

If for a minor, please include age, and school if school-related request.

Referred by

If a medical referral, please put doctor's name.

Name of person for appointment

Birth Date

This is used to verify insurance, plan benefits and rules.

Non-Insurance customers will be charged full rate. Please ask us for a Good Faith Estimate of charges based on what details you give us.

Best day of week for initial appointment

We're open Monday to Friday for initial appointments. Closed on Sundays and federal holidays.

How did you hear about us? Please check all that apply.

Internet search

Medical insurance provider search

My doctor

School counselor

Word of Mouth

Other

Mahalo for your interest in us!

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