Client Information

Name*

Gender*

Pronouns*

Please specify other gender

Please specify other pronoun

Date of Birth (DOB)*

Is Client at least 18 years old?*

Yes

No

Address*

Please select race and ethnicity:*

Please specify other race and ethnicity*

Height:*

Weight:*

Eye Color:*

Hair Color:*

Referrer Information:

PRIMARY CONTACT

Relationship*

Please describe

Name*

Address*

Home Phone:

Mobile Phone:*

Email*

Text Call Email

Sponsor:*

Yes

No

Comments:

Destination Information

Please complete this form to the best of your ability as it will assist us in engaging with your child during the initial stages of the intervention and throughout their journey to the chosen facility.

Expect to Enroll*

Is this Date Confirmed or Tentative?*

Yes

No

Destination Program / Facility

Program Name*

Drop¬Off Address*

Program Contact:*

Transportation Details

Program will collect client from us at airport*

We will drive client to program location*

If Assisted Interventions will be responsible for taking client to a medical clinic for evaluation prior to arriving at program kindly advise:

Educational Consultant

Phone

Email

Client’s Therapist

Phone

Email

Client's Psychiatrist

Phone

Email

Is client aware of plans for program?*

Yes

No

Please describe

Does client consent to treatment?*

Yes

No

Please describe

Is client aware of plans for intervention and escort?*

Yes

No

Please describe

Has client had a companion before?*

Yes

No

Please describe

Young Adult Intake Bio 18 +

We’re Here to Help!

Client Information

Referrer Information:

PRIMARY CONTACT

Destination Information

Destination Program / Facility

Transportation Details

Educational Consultant

Client’s Therapist

Client's Psychiatrist

Personal Information

Location Where Client Will Be Picked Up

Please Explain in Detail ALL of the Following that Apply

Quick Links

Other Resources

Client Intake Bio