To initiate service, please complete the following form. A representative will call within one business day to confirm the request. If you are able to come into our office, an appointment will be scheduled at that time. If you are in need of home or school based service and are enrolled in the Medicaid program, a counselor will call to schedule the appointment within three business days.

 

Your answers to the following questions are kept in the strictest confidence and will be used to assign a counselor with experience in working with your specific needs.

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Referral Source (if different than above)

Contact Information:

*Name:

*Address:

*City:

State:

Date of Birth:

*Zip Code:

*Phone:

*Email:

Client Data

Service(s) requested:

I am:

Issues to be Addressed:

Name:

Agency/School: