The City Project - Intake Form
Welcome. Please fill out the fields below and submit. You will be contacted for follow-up.
Name
First Name
Last Name
E-mail
*
Phone Number
-
Area Code
Phone Number
Are you 18 or over?
*
Yes
No
Health Insurance?
*
Yes
No
Insurance Carrier and plan (if applicable)
History of Substance Abuse?
Yes
No
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?
*
Submit
Should be Empty: