(Place a check next to the Service/s you’re interested in receiving)

Age

Gender
MaleFemale
Name of Parent/Guardian (If under 18 Years):

Email Address

Type of Insurance

Medicaid/Insurance ID

Has Psychiatric/Psychological Assessment been completed?

YesNo
If yes, please attach or provide later

Is the person currently receiving counseling services?

“If yes, we cannot service them until they’re discharged

YesNo
Is the person receiving medication?
YesNo