Mental Health Inquiry Form - INTERNAL USE ONLY

Logged by (your name)(Required)

Entry Type(Required)

Desired Service

Caller's First Name(Required)

Caller's Last Name(Required)

Are you a new patient or already seeing us?(Required)

Phone Number(Required)

Email Address

Preferred Contact Method

Are you seeking services for yourself or others?(Required)

If self, your date of birth

If child/children, their ages?

Do you have Private Insurance or Medicaid

Additional Insurance Information (if applicable)

Referral Reason/Notes for Our Scheduler

Do you have a preferred CSI Provider in mind? If so, who?

Indicate all preferred days of the week (select all that apply)

Time of day preference (select all that apply)

How did you hear about us?

If other, please explain

Mental Health Inquiry – INTERNAL USE ONLY