Ackerman Referral & Screening Form

Referral & Screening Form

Initial Inquiry Form
This form is for requesting outpatient therapy services. It is not monitored 24/7. If you are experiencing a mental health emergency, are in crisis, or are having thoughts of harming yourself or others, do not wait for a response to this form. Call 911, call or text 988 (Suicide & Crisis Lifeline), or go to the nearest emergency room.

Si hablas español y prefieres completar este formulario en español, usa la opción de la bandera en la esquina superior para cambiar el idioma.

Please note: As a Clinical Training Institute, we routinely assign cases to a clinician who is in training or on the pathway to full licensure. Supporting and supervising developing therapists is a core value of our Institute, and a longstanding tradition. Every clinician practices under the ongoing guidance and oversight of an experienced, licensed supervisor, and responsibility for clinical direction and care remains with our supervisory team.

Referral Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Source
How were you referred to Ackerman?
Referral Source Details (if applicable)
Referral Agency or Organization
Contact Person
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Your Experience with Ackerman
How did you hear about the Ackerman Institute?
Have you previously received treatment at Ackerman Institute?
Your Information
Name

Legal First Name (no nicknames)Last Name
Legal Guardian (if applicable)

Legal Guardian First NameLegal Guardian Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Your Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Borough
Gender Identity
How do you describe your gender identity?
Preferred Pronouns (Adult/Parent/Guardian)
Preferred Pronouns (Youth)
Sex Assigned at Birth
This information is collected separately from gender identity, as both may be necessary for your healthcare, insurance verification, and billing needs.
Race
Language Preference
Phone Number
Format: (000) 000-0000.
Your Email
By providing your email, you consent to receive communications from our Intake Team about your eligibility status and next steps.
What is the best way to contact you?
Please enter the email addresses of any other family members who will be participating in therapy (separate multiple emails with a comma).
Each participating family member will receive their own Patient Portal login.
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to You
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.