(Place a check next to the Service/s you’re interested in receiving)
Behavioral Health AssessmentIndividual CounselingFamily & Group CounselingParent Skills TrainingSocial & Life Skills TrainingNursing AssessmentCrisis InterventionPsychological TestingSelf-Esteem BuildingPsychiatric EvaluationMedication ManagementDiagnostic AssessmentCommunity Linkage/ SupportDrugs & Substance AbuseCoping/Skills Management
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
If yes ,
Name of medication(s) and dosage Summary of mental health circumstances Name of Physician Physician Address
Physician Phone Number