Contact Person: (if minor, parent or guardian) message?
If Client is under 18: School:
Why would you like to be seen at our facility? (please check all you may be interested in)
If you feel that you are suicidal or homicidal, please call 911 or go to the nearest emergency room! The suicide hotline number is 1-800-273-8255 if you are not immediately suicidal or homicidal but need
someone to talk to at this moment.