Service Request Form
Services Requested
*
Mental Health Counseling
Target Case Management
Psychiatric Services/Medication Management (You must be receiving Mental Health Counseling)
Where would you like services provided:
*
St Lucie County
Indian River County
Martin County
Okeechobee County
Services for Child or Adult
*
Child (5-17 years old)
Adult (18+ years old)
Full Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Back
Next
Is client out of home placement?
Yes
No
If yes,
Foster Care
Relative Placement
DCF caseworkers' name?
DCF caseworker's phone number
Is the client currently receiving services at another agency?
Yes
No
If yes, please explain where and what services:
Legal Guardian or Power of Attorney: First and Last Name
Relationship
Phone Number
Please enter a valid phone number.
Important
*If legal guardian is biological parent, the parent needs to bring the child’s birth certificate to the initial intake appointment. *If legal guardian is NOT biological parent, the guardian needs to bring proper court documentation to the initial intake appointment.
Method of Payment
Medicaid
Healthy Kids
United Health Care
Private Pay
Other
Policy Number if Known
Reason for Referral
Hyperactivity
Anxiety
Depression
Legal Problem
Family Conflict
Divorce/Seperation
School/Work Issues
Anger Management
Poor Parent/Child Relations
Grief/Bereavement
Self-Mutilation/Cutting
Suicidal/Homicidal
Defiant Behaviors
Low self-Esteem
Court Oreder
Substance Abuse/Use
Peer Conflict
Other: Explain
Primary Care Physician:
Phone Number
Please enter a valid phone number.
If Adult, Emergency Contact First and Last Name:
Phone Number
Please enter a valid phone number.
Referral Source
Are you a previous SMHC Client
*
Yes
No
Submit
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