Appointment Request Form
Please complete this form and an agency representative will be in touch to schedule an appointment as soon as possible.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Referral
*
Please Select
Self
Probation
Attorney
Drug Court
Physician
Therapist
Department of Child Services (DCS)
Other
Please let us know who is referring you.
Desired Service(s) *check all that apply
*
Substance Abuse Assessment/Treatment
Problem Gambling Assessment/Treatment
Abuse Intervention/Batterers Intervention Program (AIP/BIP)
Anger Management
Mental Health Assessment
Individual Therapy
Other
Do you have insurance?
*
Yes
No
What type of health insurance do you have?
Example: Medicaid, Anthem, HIP, Caresource, etc.
Please upload any relevant referral paperwork (if applicable)
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