INQUIRY FORM

In order to assist you, we will need an overview of information. Please fill out our inquiry form below before scheduling your call. The Applicant is the person applying for care, and the Patient is the person receiving care.

Applicant First Name *

Applicant Last Name *

Email *

Phone *

State Currently Living *

What is your preferred language? *

Patient

Patient's Name *

Relationship To Patient *

Patient's Gender *

Patient's Date Of Birth *

Age *

Current Grade *

Reading Level *

Height *

Weight *

Overview of Behavior *

SELF HARM HISTORY

Patient is Suicidal? *

Patient has hurt themself *

Patient has verbally expressed suicidal thoughts *

Patient has attempted suicide *

More details about suicide and self-harm

SELF MEDICATION

To what degree does the Patient use Marijuana *

To what degree does the Patient use Alcohol *

To what degree does the Patient use other drugs *

List any other drugs used

More details about self-medication

VIOLENCE

Is the Patient violent with Peers

Is the Patient violent with Family

Is the Patient violent with Property

Is the Patientviolent with Parents/Guardians

Is the Patient violent with Authority

More Details About Violence

COUNSELLING

Has the Patient ever been in counselling *

Select all or none that applyDoes the Patient have any of the following diagnoses? *

List any mental health medication prescribed to the Patient *

Please give more details about counselling if applicable

SEXUAL ISSUES

Does the Patient have inappropriate sexual issues? *

Does the Patient have sexual deviancies? *

More details about sexual issues

HEALTH

Patient's weight *

How active is the Patient *

Describe any health issues the Applicant has

OTHER

Does the Patient have a history of arson?

Does the Patient any eating disorders?

Is the Patient's IQ above 85?

TELL US MORE

Share with us, what is the Patient like when happy? What does the Applicant enjoy? *

Include as much detail as you can. This will help us get to know the best possible solution for the Applicant.

My financing options includes *

Time Zone *

Service(s) Interested In *

Having Problems Submitting the Form?

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