We can help you find a program or other help regardless of your situation. We are here to serve you. Please contact us using this form or call.

If Heartlight is not right for your child, or you need a less expensive option, we will help you find the appropriate program.

I'll promptly call or send any information you may need.

Melissa Nelson
Director of Admissions
and Referrals
903.668.2173 ext. 32
Fax 903.668.3453

YES! My Teen Needs Help.

First Name*
Last Name*
Address*
Town/City*
State*	e.g. AZ
Zip Code*	e.g. 75650
Phone	ext.
Fax
Email*
* Starred Items Are Required My Request (Choose one or both)
Phone me.
Send information in the mail.
Alternate phone number and extension to reach me during daytime hours:
ext.
Best time to contact me (indicate AM or PM)
e.g. After 5PM MST
My Child's Gender
Male	Female
My Child's Age	(teenagers only)
Is this an emergency or urgent?
Yes	No
Note: Emergency pick-up and escort services are usually available.
Where did you FIRST hear about us?
e.g. Radio, web search, counselor, friend
Please describe your current situation and why you need help with your teenager:


If the submit button does not work on your computer, press shift and drag your cursor from your name down to here to highlight the content, then press CTRL C. Then, open an email window and press CTRL V within the email to paste this information there. Send to admissions@heartlightministries.org.