Intake Form

Your Personal Information

Name(Required)
MM slash DD slash YYYY
Your Email Address(Required)
Address(Required)
When is the best time for us to reach you via telephone?
Type of service: (Select from the boxes below) *(Required)
Max. file size: 512 MB.
Max. file size: 512 MB.

Patient Related

Have you had any recent or past in-patient mental health hospitalizations?
Have you had any recent or past suicide attempts:
If yes, was it within the last 6 months?
Do you currently have any thoughts of harming yourself or others?

IF YES, PLEASE CONTACT 911 IMMEDIATELY OR GO TO YOUR LOCAL EMERGENCY ROOM.

Is there any history of violence towards others?
Do you now or ever had any history of drug or alcohol abuse?
If yes, are you currently using?
*If patient is under 18* Any DCF or DMH involvement?
If yes, do the parent(s) have full custody?
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