Mental Health Service Request Form
Requesting Person's Information
Name of Person Requesting Services
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Client Information
Please provide information regarding the individual needing mental health services
Client being referred is
Please Select
Myself
My child
Child in my care
Other
If "Other", please provide relationship below.
Client Name
*
First Name
Last Name
Client Gender
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Age at Time of Request
Has the client previously participated in mental health services?
Yes
No
If yes, please provide information on where and when below.
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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 Name
Last 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
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Insurance Information (if applicable)
Insurance Provider
Please Select
Medicaid
Private Insurance
Uninsured
Other
If you selected "Private" or "Other", please list insurance provider below.
Name Person Insured:
Insured Person's Date of Birth (if different than Client)
-
Month
-
Day
Year
Date
Identification Number from insurance card:
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Reason for Requesting services
Services Requested
Individual Counseling
Family Therapy
Behavioral Support
Evaluation
Trauma- Focused
Problematic Sexualized Behavior
Emotional Regulation
Are requested services due to victimization?
Yes
No
If yes, please select victimization type
Please Select
Sexual Abuse
Physical Abuse
Witness to Violence
Drug Endangerment
Other
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.
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