OurCityHeart Request Services
Filling out this form means you are asking CityHeART to connect you, your client, or your loved one to a service provider in your area that is able to meet a social or medical need that you or someone in your care may have. Once completed, this form is sent to CityHeART's YouConnect program in Long Beach, CA.
CityHeART is open from M-F 10am-2pm. Please email us at firstname.lastname@example.org
if you have not heard from our team or from another service provider regarding this request within two business days.
The information you enter is completely confidential and there is no cost for this service. Consent submitted through this form should be signed/provided by the person who would be receiving services or their parent/legal guardian only.