Mental Health & Referral Intake Form

Mental Health & Referral Intake Form

Share your details and referral information so we can connect you with the right support.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method

Other
What brings you to seek mental health or referral services?
Are you currently receiving mental health care from another provider?
Are you currently seeking support for substance use treatment?
Are you currently seeking support for domestic abuse?
If yes, please provide the provider's name and contact information.
Are you looking for a specific type of referral?

Other
Briefly describe any current mental health concerns or symptoms.
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
Do you consent to be contacted by Pass the Beauty Inc regarding mental health and referral services?
Should be Empty: