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Family Crisis Intervention Request Form
Thank you for trusting us to help you and your family during this time. Please take a moment to fill out the information below to help us know how we can best serve you. Please note that our family crisis intervention services are not emergency services. If you or a family member is having an active crisis, please call 911. You can also refer to our "resources" page for more specific support. Healing Her takes the safety and well-being of others seriously. Your request will be reviewed by our Clinical Director to assess if a higher level of support is needed and referrals will be provided accordingly. 
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What is today's date? *
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What is your name? *
Date of birth? *
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What state do you reside in? (We are only licensed in D.C., Maryland and Virginia. If you live outside of these states, we can provide a consult and referrals). 
Please describe the matter you would like to receive therapeutic support/intervention for.  *
Will this be the first time your family is learning of the matter?  *
Number of people involved? (It is best to limit this number to individuals who are primarily impacted) *
How would you like for Healing Her to intervene in this matter? (providing coping skills, stress management, grief support etc.) *
Are you or anyone in your family currently seeing a mental health therapist? *
Are you or anyone in your family diagnosed with a mental health disorder? If yes, please list the diagnosis and family member (i.e. "Aunt-depression"). *
How soon are you looking for Healing Her to intervene in this matter?  *
Please note that Healing Her does not accept insurance at this time. Clients are required to place an active card on file for payment which will be charged at the time of services. Do you agree to the above terms? *
Best phone number to contact you. *
Best email to contact you and send important documents to. *
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