Client Information
Please fill out client demographic information below:
Full Name:
Date of Birth:
Age:
Gender:
Female
Male
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Address:
Phone Number:
Email:
Parent/Guardian Information:
Please fill out parent/guardian information (if applicable):
Full Name:
Relationship to Client:
Phone Number:
Email:
Referral Source
Please fill out referral information below:
Name of Person/Referring Organization:
Relationship to Client:
Phone Number:
Email:
Date of Referral:
Reason for Referral
Please fill out the reason for reason for referral. Check all boxes that apply below:
Type a question
Behavioral Concerns
Emotional Difficulties
Family Conflict
School-Related Concerns
Crisis
Other
Services Requested
Please select services requested below:
What service(s) will the client be interested in?
Intensive In-Home Services Our Intensive In-Home Program provides compassionated personalized support for children and teens struggling with emotional, behavioral, or family challenges- right in their own home and communities.
Outpatient Therapy Our Outpatient Therapy offers safe, confidential spaces for individuals and families to process life’s challenges. Our licensed therapists use evidence-based methods to treat anxiety, depression, trauma, and more — both in-person and via telehealth.
Mental Health Skill Building/ Mentoring Our MHSB program equips adults with serious mental health conditions with the tools they need to thrive independently. From managing emotions to organizing finances, we focus on real-life skills for sustainable wellness.
Crisis Intervention When the unexpected happens, we’re here. Our Crisis Intervention Program offers immediate, in-person support for youth and adults facing emotional or behavioral emergencies — helping de-escalate, stabilize, and connect you with the right resources fast.
Other
Insurance Information
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Insurance Provider:
Policy Number:
Primary Insured Name:
Signature
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Signature
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