Your Mental Health Is important & there is nothing wrong with getting a little help
- we got you!!

We know the urgency of wanting to gain control of your emotions and thoughts. It’s like everything was going so right and BOOM! *A job layoff, *car repossession, *eviction notice, *failed test or grade now got you thinking if you are not smart or good enough, *experience of bullying, *random disappointments of ALL sort, *violation of your boundaries, *a bad break-up, *abandonment from someone who is suppose to love you, *loss of a loved-one, *fall-out with family or friends, *or life is just happening & everything seems to be spiraling out of control. Mental health is learning how to apply your EQ – Emotional Intelligence, and IQ – Intellectual Intelligence with all of your life’s experiences that has made you strong and resilient. You are so qualified to survive whatever it is that you are feeling right now, and we are here to help you remember your strength and resiliency. Everyone experiences ups & downs, and that’s why it is important to always have someone who can understand your situation without judgement.

BREATHE ….. Take the time to fill out the information below. We will contact you in the next hour or so to get you squared away, or help in guiding you to where you need to go if we can’t assist you.

Who Referred You:

Client's First Name:

Client's Last Name:

Client's Date Of Birth:

Client's Social Security Number (For Insurance verification only):

Guardian's Name (if under 20yrs old):

Best Contact Number:

2nd Best Contact Number:

Email Address (the one you check often)

Are you insured?

Yes No out of pocket client

Primary insurance name: (ENTER N/A IF NOT APPLICABLE)

Please enter your insurance identification number from your card if you have it: (ENTER N/A IF NOT APPLICABLE)

Is the client receiving mental health services any where else at this time? (Please enter details of this answer is YES)

Is there anything important you want us to know?

The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the agency documenting the information. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by the email or business above & destroy this copy immediately.

Your Mental Health Is important & there is nothing wrong with getting a little help - we got you!!

BREATHE ….. Take the time to fill out the information below. We will contact you in the next hour or so to get you squared away, or help in guiding you to where you need to go if we can’t assist you.

Your Mental Health Is important & there is nothing wrong with getting a little help
- we got you!!