APPLICATION FOR SERVICES
This form is a part of your C4MH record, and the information provided will be treated as confidential. This information is required in order for us to identify your need and provide you with services. The C4MH provides services and benefits to its clients without regard to race, color, religion, gender, national origin, age, handicap, or economic status.

IS THIS A CURRENT EMERGENCY CRISIS?

PLEASE COMPLETE THIS APPLICATION SPECIFIC TO THE PERSON SEEKING SERVICES

Complete only if appplicant is under the age of 18 OR if the client has a legal guardian.

INSURANCE INFORMATION