757-227-3636 info@infinitycounselinggroup.com

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Please take a moment to completely fill-out our service request form.

Service(s) Referred for

TDT (Therapeutic Day Treatment)
IIH (Intensive In-Home)
MHSB (Mental Health Skill Building)

Other Services Requested

Name *

First

Last

Address *

City / State / Zip

Email

Phone *

Alternate Phone

Date of Birth

Age

Gender

Legal Guardian(s)

Does the client reside in a foster home?

Yes
No

Name of Legal Guardian

Relationship to client

Guardian Phone

School Name

Grade

Does the client have an IEP?

Yes
No

Referred By

Title

Infinity referral point of contact

Referral Contact Phone *

Referral Contact Alt. Phone

Referral Contact Email

Pressing behaviors (reason for referral)

History of psychiatric hospitalization?

Yes
No

If Yes, please note when and where treatment was provided

Current medication(s)

Past/Current mental health or substance abuse treatment, school-based interventions, and/or legal involvement?

Yes
No

If Yes, with whom

Comment

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