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
*	Email
	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