Counseling Intake Form
Schedule an intake appointment for counseling services. An intake is an opportunity to discuss your presenting concerns and develop a treatment plan with a counselor based on your needs.
CORE Referral Form
Make a referral for CORE (Counseling, Outreach and Referral for the Elderly) services. CORE is a mental health, substance use disorder counseling and care coordination program for people 55 and older.
Daybreak Clubhouse Referral Form
If you or a loved one are interested in joining Daybreak, this form must be completed by your doctor and emailed to Alicia Nicholson at firstname.lastname@example.org
Medical Release Form
Request for and release of protected health information. Click here for filable/printable form.