Form
Mental Health Services Referral & Intake Form
You don’t have to navigate this alone. This form is the first step in connecting you, or someone you care about, to supportive, compassionate mental health services. Once submitted, a member of our care team will review your information and reach out to discuss next steps. Completing this form does not obligate you to services—it simply helps us understand how to best support you.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What is the best way to reach you?
*
Phone call
Email
No preference
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who referred you to us?
*
Please Select
Community Partner
Other Nonprofit
Medical Provider
Social Service Agency
Other Mental Health Agency
School
Church
Self-referral
Do you currently have insurance?
*
Yes
No
If you currently have insurance, please provide the name of your insurance.
If you do not currently have insurance, do you need to request financial assistance?
Yes
No
Need to discuss
Are you looking for individual or group mental health services? (select all that apply)
*
Individual
Group
Both
Have you participated in mental health services in the past?
*
Yes
Yes, but it's been more than 1 year
No, it's my first time
What kind of mental health services are you looking for? (select all that apply)
*
Trauma
PTSD
Anxiety or panic disorders
Depression
Mood disorder
Perinatal mood & anxiety
Post-partum depression
Grief & loss
Caregiver burnout
Life transitions & identity shifts
Attachment or separation anxieties
ADHD
Cognitive/daily living
Other
Please give a brief description of why you are seeking mental health services.
*
0/1000
By signing electronically below, I acknowledge that this is not a guarantee of services. I am giving permission to Restored & Revived to have basic & general information about the contents of this form and I am also giving Restored & Revived permission to contact me regarding mental health services.
Date
*
-
Month
-
Day
Year
Date
Signature
Continue
Continue
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