Request Services (Self-Referral)

Services are for

An adult (18 and over) A child or teen (under 18)

I am

The person seeking services A parent or guardian A family member or friend (with the person's permission)

Your name (if you are not the person seeking services)

Relationship to the person

Your phone number

Your email

Full name

Date of birth

Preferred name / pronouns

Phone number

Is it OK to leave a voicemail?

Yes No

Email

Is it OK to email?

Yes No

Home address

City

State

ZIP code

County

Currently without stable housing

Insurance

Medicaid / member number (optional)

Parent / guardian full name

Relationship to the child

Parent / guardian phone

Parent / guardian email

School and grade (optional)

Agency involvement (optional)

None DSS DJJ Other

Check all that apply

Psychiatric Rehabilitation (PRP) Outpatient mental health therapy Therapeutic Behavioral Services (TBS, children) Rehabilitative Mentoring (youth) Substance use treatment (ASAT) Not sure, please call me

What would you like help with?

Are you currently seeing a therapist, psychiatrist or doctor?

Yes No

If yes, name / agency and phone

Best times to reach you

Weekday mornings Weekday afternoons Weekday evenings

I agree that Changing Turn may contact me about this request and use this information to review it. I understand this request is not an appointment and does not start treatment.

Type your full name as your signature

Date

Self-Referral (Client / Family)

Who is this request for?

Who is filling out this form?

About the person seeking services

Parent or guardian

Services you are interested in

A little about what is going on (optional)

Consent

Our Services

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