Intake Form

Please fill out the following form to help us understand your needs.

First Name

Social Security Number

Guardian's Phone Number

Last Name

Date of Birth

Guardian's Email

Has your child experienced any of these in the last 30 days *

Suicidal/Homicidal Ideation(Thoughts)

Anxiety

Depression

Anger/Rage

Grief/Loss

Change in sleep patterns

Change in eating patterns

None

Other

Has your used any substance within the last 30 days? If yes, please provide the name of the substance

What would you say is your immediate need for your chlild?

Therapy

Mentoring

Tutoring

Art and Music Therapies

Juvenile Services

Food

Other

Has your child ever received services in the past? *

No

Yes

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Business Hours

Corporate Office : Mon - Fri: 9am - 5pm

Fax 443-519-5566

1-877-839-3989

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