Request for Services + Information
Please fill out this form to have a member of our Intake Team call you. Completion of this form is not a guarantee of services.

Insurance accepted: OHP through Pacific Source, Trillium, and Open Card

Please type NA in fields which are Not Applicable to your request for services.
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Name of Person Being Referred: *
Pronouns: *
Date of Birth *
MM
/
DD
/
YYYY
School Attending (or NA) *
Grade in School (or NA) *
Parent/Legal Guardian's Name (if person being referred is a child or NA) *
Address *
City *
Zip Code *
Preferred Phone Number (we will call this number to schedule intake) *
Email Address
Referral Source (Name of Organization)
Name of and Title of Person Referring (if different than Parent/Legal Guardian listed above)
Phone Number of Referral Source
If you are completing this form on behalf of a child/family which is not your own, are they aware this referral is being made? (Please note that the legal guardian must be aware in order for us to proceed.) *
If the client is 14 or older, may we contact the parent? *
If we are not authorized to contact the parent, please provide a phone number where the client may be reached.
Insurance Name (We currently only accept OHP through Pacific Source, Trillium, and Open Card.) *
Insurance Subscriber Number *
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This form was created inside of The Child Center.