Adult Mental Health Intake Form
(Adult refers to those aged 19+)
Please fill out the form to the best of your ability.
If you do not know or do not feel comfortable filling out the information below, that is alright. The more information you can give, the better it will help REACH determine a support plan for you. If this referral is for yourself, you do not need to fill out the Referee Information. If you are filling this form out for a person you are concerned for and who has given consent to seek more information or support, please fill out the Referee Information