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The Harlem Family Institute - Request for Services Form
PLEASE NOTE:

If this is a medical or psychiatric emergency, please go to the nearest hospital emergency room or contact 911. The Harlem Family Institute is unable to respond to psychiatric emergencies through its website.

Please do not include your mental health history when contacting us through our website.

This contact form is for the purpose of requesting an intake appointment and not intended to open a dialogue or as a place for questions about care. These issues can be addressed during the initial intake session.

All emails and completed requests for services forms will be responded to with a return phone call.
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Date of Referral: *
MM
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Are you aware of and agreeable to this referral? *
On a scale of 1 to 5,  where 1 is not urgent and 5 is very urgent, how urgent is your request? *
Client Information
Please answer a few questions about you so we may contact you. Please note that without proper contact information, we will not be able to make contact with you.
Name : *
Birth Date: *
MM
/
DD
/
YYYY
Age : *
Gender : *
Race/Ethnicity
Parent/Guardian Name (if under 18 years):
Parent/Guardian Phone number (if under 18 years):
Did Parent/Guardian sign consent form?
Clear selection
Address:
What are you seeking support with today? *
Home Phone:
May we leave a message ?
Clear selection
Cell Phone:
May we leave a message ?
Clear selection
Email:
May we email? (Email is not considered to be a confidential medium of communication).
Clear selection
Please click here if the case involves a child at CPE1 or Castle Bridge elementary school or at Little Pebbles Nursery School.
Clear selection
REFERRING PROFESSIONAL
If you are a helping professional or other third party making a referral on behalf of someone, please complete the following questions.
Referring Entity Name
Address:
Phone:
E-mail :
Submit
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