Page Title

Referral Screening

If you are unsure of whether or not a consumer is eligible for one of
our services and would like to request a preliminary screening, please
submit the form below. Someone will be in touch within 24 hours of
receipt.

Please enter the consumer's first
name or initials:

Please select the following for
age/sex of consumer:

Please select what
service you would like us
to screen (to select more
than one service, hold
the "Control" key:

Please enter an
estimated start date
of service requested:

Please indicate what current
MH services the consumer is
receiving:

Please indicate below if
the consumer is receiving
special education services
and has a current IEP: (list
name of school and
contact if available)

Please select the reason for
requested screening below:

Please indicate to the right, consumer's Axis I & II
Diagnosis:

Please enter your name,
email address and contact
number:

Please indicate
consumer's funding
source:

Feel free to contact Trish
Wisse, Intake Director at
(919) 514-7500 Ext. 1101
twisse@hopeservices4u.com