Contact 1 — The Legacy Team

Welcome to The LEGACY TEAM

We prioritize the individual needs of our clients in order to minimize ongoing risk, encourage overall wellbeing, foster self-sufficiency and promote healing, while simultaneously accessing the community resources needed to support long term stability.

Initial Assessment Form

Please complete this Initial Assessment Form and a representative will contact you to review any details and schedule your first appointment with one of our Team Professionals.

Potential Client Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Current Age

What Mental Health Issues Are You Experiencing Now?

How Long Have You Been Experiencing These Issues?

List Any Current Medications You Are Taking

List Any Therapeutic Services You Have Received Already

Please provide the name of any doctors or programs that you have visited for your mental health concerns.

Services You Are Interested in Now

Trauma Focused Behavioral

Outpatient Therapy

Peer Support Services

I Am Not Sure

How Did You Hear About Us?

Insurance Information

Medical Insurance Provider Name

Medical Insurance Group Number/ Policy Number

Parental Information

If the potential client is under 18 years old

Parent Name

First Name

Last Name

Phone

(###)

###

####

Relationship to the Potential Client

Welcome to The LEGACY TEAM

Outpatient Therapy I Trauma Focused Cognitive Behavioral Therapy I Peer Support Services

800.269.8090