• Intake Form

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is the person seeking care under 18?*
  • Who is filling out this form?*
  • Does a parent or guardian know you're looking for care, and are they willing to be involved?*
  • Thank you for reaching out. For anyone under 18, CMHS needs a parent or guardian to be part of starting care. If you can, talk with a parent, guardian, school counselor or doctor about getting help. If you're in crisis, call or text 988 any time, or 911 if you're in danger.
  • Format: (000) 000-0000.
  • Is it OK for us to text this phone number about scheduling?*
  • Who has legal decision-making authority for the teen's medical and mental health care?*
  • Is there a court order or guardianship document that covers the teen's medical or mental health decisions?*

  • We're sorry: our practice isn't able to accept Medicare or Medicare Advantage plans, so we can't schedule care through this form.

    To find a provider who takes your plan, call the member services number on your insurance card or use the "Find care" tool at medicare.gov. You can also call 2-1-1 for help finding services in Connecticut.

    If you are thinking about harming yourself or someone else, call or text 988 any time. If you are in immediate danger, call 911.

  • Is this insurance in your name?
  • Policyholder's date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is it OK for us to text this phone number about scheduling?*
  • What type of care are you seeking?*
  • Are you taking three or more daily prescription medications of any kind?*
  • Would you like to start with therapy, start with medication, or begin both at the same time?*
  • What are you hoping to get help with?
  • In the past 2 weeks, have you had thoughts of harming yourself or others?*
  • Have you attempted suicide in the past 60 days?*
  • Are you experiencing hallucinations or severe mental health instability?*
  • Have you been hospitalized or in an intensive outpatient program for mental health in the last three months?*
  • Are you currently in treatment with Suboxone, methadone, or another medication for opioid or alcohol dependence?*
  • Have you ever been diagnosed with a psychotic disorder, such as schizophrenia or schizoaffective disorder?*
  • Have you ever been diagnosed with bipolar disorder?*
  • Are you seeking in-person, virtual, or hybrid therapy?*

  • Once you submit, our intake team will call you from (203) 651-5117 within the hour, or first thing on our next open day (Monday to Thursday 9am to 3pm and 4:30 to 6:30pm, Friday 9am to 3pm), to match you with a clinician and go over cost.

  • Thank you for reaching out. Based on your answers, you may need more urgent care, or more support, than our practice offers.

    If you are thinking about harming yourself or someone else, call or text 988 now. If you are in immediate danger, call 911 or go to the nearest emergency room.

    CMHS provides standard outpatient care: scheduled therapy and medication appointments. We can't provide the more immediate or intensive support your answers suggest, so we are not able to begin treatment with you at this time. This form is not checked in real time. Submitting it will not start care, and our office will not call you about it.

    To find a program that offers more support, call 2-1-1 or visit 211ct.org, any time, day or night. Your doctor, or the member services number on your insurance card, can also help.

  • Thank you for reaching out. Based on your answers, you may need more urgent care, or more support, than our practice offers.

    If you are thinking about harming yourself or someone else, call or text 988 now. If you are in immediate danger, call 911 or go to the nearest emergency room.

    CMHS provides standard outpatient care: scheduled therapy and medication appointments. We can't provide the more immediate or intensive support your answers suggest, so we are not able to begin treatment with you at this time. This form is not checked in real time. Submitting it will not start care, and our office will not call you about it.

    To find a program that offers more support, call 2-1-1 or visit 211ct.org, any time, day or night. Your doctor, or the member services number on your insurance card, can also help.

  • Date/Time of Form Submission
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: