Behavioral Services Intake Form Behavioral Services New FormBasic Client Information:Full Name:Email:Phone/Mobile:Date of Birth:Preferred Contact Method: Call Text EmailGender Identity:- Select -FemaleMaleNon-binaryPrefer not to sayParent/Guardian Name (if under 18):Parent or Guardian Phone #:Race / Ethnicity:AddressCityStateZip CodeCountryUnited States (US)AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweSelect the Service You’re Seeking:- Select -Adult Rehabilitative Mental Health Services (ARMHS)Mental Health SupportCrime PreventionDrug Abuse PreventionAdult Rehabilitative Mental Health Services (ARMHS)Have you been diagnosed with a serious mental illness (SMI)? Yes No Not SureAre you covered by Medical Assistance (MA)? Yes No PendingDo you have a current mental health assessment? Yes NoAre you currently receiving case management or therapy? Yes NoWhat kind of support do you need? Daily living skills Medication management Social skills Emotional regulation OtherIf other, specify itDate of most recent assessment:Mental Health Support:Are you seeking support for yourself or someone else? Self Someone elseHave you ever received therapy before? Yes NoAvailability for sessions:Reason for seeking support: Anxiety Depression Trauma Family issues Adjustment OtherIf other, specify itPreferred setting: In-person Virtual No preferenceCrime Prevention:Are you currently involved in the justice system? Yes NoHave you experienced violence or witnessed crime in your community? Yes NoWhat type of support are you seeking? Are you seeking: Anger management Conflict resolution Peer mentorship Restorative justice OtherIf other, specify itDrug Abuse Prevention:Are you seeking help for yourself or someone else? Self Someone elseDuration of use:Is there a current crisis or risk of overdose? Yes NoDo you need Narcan/Naloxone information or access? Yes NoSubstances involved: Alcohol Opioids Prescription drugs Marijuana OtherIf other, specify itAre you interested in: Education/Prevention Treatment referral Peer support Counseling OtherIf other, specify itAdditional Information (Optional)How did you hear about this program?- Select -SchoolSocial MediaSearch EngineFriendCommunity EventWebsiteOtherAnything else you'd like to share? I understand this information is confidential and only used to assess eligibility and support needs. I consent to be contacted by Isuroon staff.Submit Form
