Driver's License No. & State:
Did anyone refer you to MHRC? If yes, please list.
May we leave a message at this number?
CLIENT INFORMATION Must be completed by the client (unless under the age of 16)
May we use this email for correspondence regarding this inquiry/intake?
Street, City, State & Zip Code
Have you attended any previous counseling or treatment?
Did you complete the program?
Are you currently on or have you ever been on psychiatric medication(s)?
If yes, please list the medication(s), your diagnosis and your medical doctor's information:
What service(s) would you like MHRC to provide?