(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
Name of Parent/Guardian (If under 18 Years):
Type of Insurance
Has Psychiatric/Psychological Assessment been completed?
If yes, please attach or provide later
Is the person currently receiving counseling services?
“If yes, we cannot service them until they’re discharged
Is the person receiving medication?
If yes ,
Name of medication(s) and dosage
Summary of mental health circumstances
Name of Physician
Physician Phone Number