Mental Health Service Request Form

Mental Health Service Request Form
Requesting Person's Information

Caregivers or Legal Guardians: Please complete this form to request mental health services on behalf of your child. A member of our team will follow up with you shortly.
Name of Person Requesting Services*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Client Information

Please provide information regarding the individual needing mental health services
Client being referred is
If "Other", please provide relationship below.
Client Name*

First NameLast Name
Client Gender
Client Date of Birth*

MonthDayYear
Date
Client Age at Time of Request
Has the client previously participated in mental health services?

YesNo
If yes, please provide information on where and when below.

Client's Legal Guardian

If the requesting person is NOT the legal guardian of the client needing services, please complete the information below.
Legal Guardian Name (if different from person requesting services)

First NameLast Name
Legal Guardian Phone Number (if different from person requesting services)
Please enter a valid phone number.
Legal Guardian Email (if different from person requesting services)
example@example.com

Reason for Requesting Services
Services Requested

Individual CounselingFamily TherapyBehavioral SupportEvaluationTrauma- FocusedProblematic Sexualized BehaviorEmotional Regulation
Are requested services due to victimization?

YesNo
If yes, please select victimization type
If "Other" please provide victimization type below
Brief Description of the client's current needs/concerns*
Thank you for contacting us! One of our staff members will contact you to discuss scheduling.
Should be Empty:

Requesting Person's Information