• Individual Services Screening Form

    Crescent Counseling Center ยท Intake & Access
  • Please answer the questions below so our Intake & Access team can review your request and contact you about next steps. We may need more information before scheduling an initial assessment. Completing this form does not guarantee an appointment or admission to services.
  • This form is not monitored continuously and is not an emergency service. If you are in immediate danger or experiencing a medical emergency, call 911 or go to the nearest emergency department. For suicide or emotional crisis support, call or text 988.

  • Person completing this form:

  • Who are you completing this form for?*
  • Format: (000) 000-0000.
  • Preferred contact method*
  • How do you plan to pay for services?*

  • Person Seeking Therapy & Contact Details

  • Date of birth*
    ย -ย -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • How should we contact you or the person seeking therapy?*
  • May we leave a voicemail that identifies Crescent Counseling Center?*
  • Is the email address provided safe for us to use?*

  • Mental Health Services Request

  • What kind of therapy are you seeking?*
  • Which concerns are relevant to this request?*
  • Has anyone recommended a particular therapy, specialist, or more intensive service?*
  • Are you currently receiving mental health services, or have you received them before?*
  • Are you transferring from another therapist or planning to continue seeing one?*
  • Have you previously been given a mental health diagnosis?
  • Are you currently taking any medications?
  • Is this request connected to a court order, custody matter, evaluation, disability determination, or requested letter or report?*

  • Children & Family Services

  • What is your relationship to the child?*
  • Who has legal authority to make healthcare decisions for the child?*
  • Are there custody, guardianship, or court orders affecting treatment, contact, or access to records?*
  • Is there any disagreement about the child receiving therapy?*
  • Are there restrictions or safety concerns about contacting another parent or guardian?*
  • Format: (000) 000-0000.
  • May we leave a voicemail?*

  • Safety and Clinical Review

  • Are you or the person seeking services in immediate danger, unable to stay safe, or experiencing a medical emergency right now?*
  • Are you currently having thoughts of suicide or harming yourself?*
  • Have you recently attempted suicide, intentionally injured yourself, or received emergency help for these concerns?*
  • Are you currently having thoughts of seriously harming someone else, or have there been recent serious threats or violence?*
  • Have you recently received psychiatric hospitalization, emergency psychiatric care, or crisis services?*
  • Are you experiencing unusual perceptions, severe confusion, or very little sleep with unusually high energy or risky behavior?*
  • Is alcohol or drug use affecting your safety, daily functioning, or ability to participate in services?*
  • Have you recently experienced an overdose, or are you concerned about withdrawal?*
  • Are eating, restriction, purging, or related health concerns a reason you are seeking services?*
  • Are symptoms making it difficult to meet basic needs or care for yourself or someone who depends on you?*
  • Is there another concern you would prefer to discuss before scheduling?*

  • Scheduling and Coordination

  • How would you prefer to meet?*
  • How did you hear about Crescent?*

  • Medication Management

  • What medications are you currently taking?
  • Have any medications recently been started, stopped, or changed?*
  • Are records from a current or previous prescriber, psychiatric evaluation, hospital discharge, or recent laboratory work available?*
  • Do you have any medication allergies?*
  • Should be Empty: