Behavioral Health Intake Requests
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Your Name *
Youth's Name *
School's Name *
Email *
Child Date of Birth *
MM
/
DD
/
YYYY
Zip Code *
Has Insurance *
Insurance Type
Medicaid/Insurance ID Number
Best Call Back Number *
Best Call Back Time
The above information provided by you is necessary for starting your intake process. By checking this box, you acknowledge that you understand the information provided above will be accessible by Alternatives intake staff. This Staff will directly work with you to match you with appropriate care across Alternatives' network of services. Information you provide in this form is confidential. *
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