Family in Crisis Form
We’re here to help. Please fill out this form as accurately as possible so we can determine the best treatment options for your child. Important: If this is a life-threatening emergency, please call 911 or go to the nearest emergency room.
Step 1: Tell Us About Your Child
Child's Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
State of Residence
Please Select
California
Oregon
Washington
Idaho
Arizona
Utah
Other
If other, what's your state of residence?
Step 2: Current Situation
Is your child currently in the hospital or dealing with a medical crisis?
Yes
No
Where is your child right now? (Select one)
At home
In a hospital ER
In a detox facility
In a psychiatric unit
In an outpatient program (IOP, PHP)
Other
If other, where is your child right now?
What type of treatment are you looking for? (Select all that apply)
Residential Treatment Center (RTC)
Intensive Outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Not sure - I need help deciding
Do you have any barriers to treatment placement? (Select all that apply)
Insurance limitations (coverage, approvals, denial, etc.)
No available beds in local programs
Declined from programs
Financial constraints (out-of-pocket costs, no insurance)
Legal concerns (court involvement, guardianship issues)
Transportation challenges
Other (please describe)
If other, what are your barriers to treatment placement?
Has your child previously received mental health treatment? (Check all that apply)
Psychiatric hospitalization
ER visit for mental health concerns
Residential Treatment (RTC)
Intensive Outpatient (IOP)
Partial Hospitalization (PHP)
Therapy/counseling
Psychiatric medication management
None of the above
What are your main concerns right now? (Select all that apply)
Suicidal thoughts or behaviors
Self-harm
Severe depression or anxiety
Substance use
Aggressive or violent behavior
Psychotic symptoms (hallucinations, delusions)
Running away
School refusal or failure
Eating disorder concerns
Inappropriate sexual behavior
Inappropriate porn behavior
Other (please describe)
If other, what are your main concerns right now?
Step 3: Parent/Guardian Contact Information
Parent/Guardian Name
First Name
Last Name
Your Relationship to the Child
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method: (Select one)
Email
Text message
Phone call
No preference
Submit
Should be Empty: