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Application for Services
Please fill out the following form to help us understand your needs.
First Name
Last Name
Insurance Company
Social Security Number
Phone Number
Insurance Member #
Date of Birth
Email
Have you experienced any of these in the last 30 days
Suicidal/Homicidal Ideation(Thoughts)
Anxiety
Depression
Anger/Rage
Grief/Loss
Change in sleep patterns
Change in eating patterns
Change in sex patterns
None
Other
Have you used any substance within the last 30 days? If yes, please provide the name of the substance
What substances have you used in the past?
Tobacco
Marijuana
Alcohol
Heroin/Opioid
Cocaine/Crack
Methamphetamines
Prescriptions
Gambling/Lottery
Food
Other
Have you ever received inpatient or outpatient rehab services
No
Yes
Have you received or managed your mental health in the past?
Yes, in the past
Yes, Currently
Never received mental health care in the past
No, not currently managing
I declare that the info I’ve provided is accurate & complete. I understand this is an application for services with financial obligations. I am applying for services and know that I will be notified of all possible payment options to include my insurance company, government assistance, if possible and scholarship funding.
Today's Date
What services ar you in need of?
How did you hear about us?
Internet
Agency referral
Family member
Other
If angency referral is selected: Enter name below.
Submit
Thanks for submitting!
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