®

MENTAL HEALTH AMERICA
OF FRANKLIN COUNTY
538 E. Town St. Suite D
Columbus, OH 43215
614-221-1441

Please fill out this form and click the "Print" button below.
Send the completed form, along with a check made payable to MHAFC, for $15.75 (one-time fee for a 5-year subscription, includes postage), to the above address.

* Name:
* Street Address:
* City:
* State:
Zip:
* Phone #:
Email:
* Baby's Birthdate:
* Baby's First Name:
Name of Hospital:
* I participate in the following parenting/assistance program(s):
 WIC LEAP Head Start
Early Start GRAD
Other
Baby's Mother's Age:
Baby's Fathers Age:
Marital Status:
Years of school completed:
Annual Income Level:
Baby's Race:
* indicates required field
This information is kept strictly confidential and is not distributed to any other agencies or used for marketing purposes.