Outpatient Programs Individual/Family Counseling Substance Abuse SEED (After School Program) PSR Adults Client First Name Client Middle Name Client Last Name Address City State AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District Of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming AS American Samoa GU Guam MP Northern Mariana Islands PR Puerto Rico VI US Virgin Islands DC Washington, DC Zip Code Phone Secondary Phone Email Legal Guardian Name Legal Guardian Ralationship Legal Guardian Phone Number Documentation? Yes No Emergency Contact Name Emergency Contact Phone Number School Name Grade Level PreK Kindergarden 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Language Preference English Spanish Creole Other Race White African-American/Black American Indian Multi-Racial Asian or Pacific Islander Ethnicity Cuban Mexican Puerto Rican Other Hispanic Haitian Other Insurance Provider/ Medicaid Insurance ID Number/Medicaid # Other Method of Payment Self-Pay Pro-Bono Primary Care Physician (PCP) Name PCP Address PCP City PCP State AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District Of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming AS American Samoa GU Guam MP Northern Mariana Islands PR Puerto Rico VI US Virgin Islands DC Washington, DC PCP Zip Code PCP Phone Number PCP Fax Number Decline in school functioning Decreased Grades Poor Behavior Poor School Attendance Aggressive/Disruptive Behavior Defiant Argumentative or Uncooperative Fire Setting Arrested Hyperactive/Impulsive Distracted/Poor Focusing Anxiety Irritability Worries Sad Mood Depression Sleep Problems Social Isolation Poor/Increased Appetite Mood Swings Intense Anger Emotional Outbursts Sucidial Ideation Homicidal Ideation Sexual Abuse Victim Schizophrenia Hears Voices Hallucinations Delusions Family Problems Phobias (Describe) Danger to Self or Others (Describe) Inappropriate Sexual Behavior (Describe) Dx of ID/ASD/Neurological Disorder (verbal/nonverbal/level of functioning) Substance Abuse (Describe current/history of use) Marchman/Baker Act Recent History of (Dates Admitted/Length of Stay) Other (Describe) Telehealth Yes No Is client currently involved with any agency/mental health provider (DCF, DJJ, PO, JPO, PSY, etc.) Yes No If yes, Providers name Providers Phone Referring Agency/School Name Staff 's Name Staff Contact Phone Number Staff Email Address Submit
