EmailMe Form - Inquiry Form

Who is completing this form?

Potential client

Parent/Guardian

Referring Worker

Other

If a referring worker is completing this form, please include name, agency and contact information:

Potential client’s Legal name: *

First Last

Potential client’s DOB: *

MM / DD / YYYY

Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email address: *

Contact number: *

### - ### - ####

Is it OK if LFCS staff corresponds with you via email: *

Yes

No

Do you have immediate family members who work at LFCS?: *

Yes

No

What is the primary reason for seeking services?: *

Are there any safety concerns (self-harm, harm to others, suicidal ideations, homicidal ideations)?: *

Yes

No

Please explain safety concerns

Do you have specific days or times needed for the initial session?:

Our psychiatry sessions are during the day- Mondays, Wednesdays, and Fridays 8:30am-12pm (last start time would be 10:30am) and Tuesdays 8:30-3pm (last start time would be 1:30pm). The initial session is 1.5 hours and further session are 30 minutes. *

Our psychiatry sessions are during the day-

How did you learn about LFCS?: *

Do you have the ability to consent to services? *

Yes

No

Parent/Guardian (1) Name

First Last

Parent/Guardian (1) Phone

### - ### - ####

Parent/Guardian (1) Email

Parent/Guardian (2) Name

First Last

Parent/Guardian (2) Phone

### - ### - ####

Parent/Guardian (2) Email

Emergency contact (optional):

Are you interested in learning more about our grant funded counseling services?

Yes

No

The following questions are for demographic purposes. These are optional.

What is the race of the client?

What is the household income of the client (or parent/guardian):