Behavioral Health Services Form

Request more information or Schedule an appointment! Please complete the form below.

Behavioral Health Services Form

	Today's Date (mm/dd/yyyy)
*	Name
*	Address
*	City, State, Zip
	Birthdate (mm/dd/yyyy)
	Phone or contact method (relay, tty, VRS)
	Parent or guardian name, if applicable
	Name of School attended
	Did you graduate?
	If yes, what year?
	Reason for referral (why you are coming to HDS – what are the problems)
	Referral Source (who told you about or sent you to HDS)
*	Allergies to medicine (if you have any)
	Do you have: (hold CTRL to multi-select)
	Do you have insurance?	Yes No
	Kind of insurance
	Insurance through work
	Medicaid/Medicare
	Insured ID #
	Effective Date
	May we contact you by phone/relay/TTY/VRS?
	May we contact you by mail?	Yes No