New Client Intake Form

SUNLIGHT CENTER FOR CHANGE

New Clinical Intake Form
1627 N. Swan Rd. STE 101

Tucson, AZ 85712

Telephone: 520.344.0056

E-mail: SunlightDesk@gmail.com
Please do not fill out this form if there is imminent danger. Contact #988 or #911 for emergency services and/or go to the nearest hospital.
Thank you for your interest in clinical services at Sunlight Center for Change.

Once this form is submitted, you will be on our active waiting list and someone will contact you with the next available opening. Therapy may be in person or online depending on the appropriatenss and the need.

Please note that we do not accept insurance. Payment is required at the time of services. If you have insurance, please contact them directly to find out if they will reimburse you and in what amounts for out of network providers. Hourly rates for a clinical hour can range depending on the service and the provider from $125 - $175/hour.

If you have additional questions, feel free to contact us at SunlightDesk@gmail.com.

Thank you.
Date

MonthDayYear
Date
Who referred you to us?*
Person Completing this Form (Your Name) *

First NameLast Name
Person Completing this Form Phone #:*
Email*
example@example.com
Relationship to the client needing services*
Type of Service Requested:*
If other, what are you seeking?
Is this court involved?*

YesNoIt will beI don't know

For Child involved cases
If the client is a minor, who has legal custody? (upload parenting plan or custody order if applicable)
File Upload

Cancelof
What is the name of Parent 1:
Parent 1 Phone #
Parent 1 Email
attorney name (if applicable)
email address
example@example.com
What is name of parent 2
Parent 2 Phone Number
Parent 2 email address
example@example.com
attorney name (if applicable)
Is there a Court Order pertaining to this service being requested? (upload)*

YesNo
File Upload

Cancelof
If there are legal Custody Orders in place, this MUST be on file. Are you providing it? (upload)

YesNo
File Upload

Cancelof

SUNLIGHT CENTER FOR CHANGE