The City Project - Intake Form
Welcome. Please fill out the fields below and submit. You will be contacted for follow-up.
Are you 18 or over?
Insurance Carrier and plan (if applicable)
History of Substance Abuse?
Yours and/or Family History with Mental Illness
Current Medication or Therapy?
Current Social Support System? (Friends, Family, Support Groups, Etc.)
Current Symptoms and duration
How has Mental Illness Affected your Life?
Known Triggers of Illness?
Goals of Treatment?
Should be Empty:
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