Please fill out the fields below and submit. You will be contacted for follow up.

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? *
Should be Empty:

The City Project - Intake Form