Alliance Mental health and Youth Consultation Services, LLC
This form should be completed by prospective clients or former clients that have not been seen in more than six months.
All information provided should be for the potential client.
We do need consent from both parents / guardians to treat a minor. Ideally the provider would prefer to meet with any responsible parties before meeting the potential client. If that isn't possible, consent can be given by email / phone but it does need to be received before they can be seen. It is the responsibility of the parent / guardian initiating contact with us to secure that consent.
Please note that all clients are asked to do their first appointment in the office.
Please describe what problems you'd like to address and/or why you are seeking counseling.
Providing details will help the screening go more smoothly. Without enough detail to review the case, your screening will not be processed.
Please note that for ethical reasons Individual and Family/Relationship counseling cannot be performed by the same provider. In cases where both are warranted two providers will need to be assigned.
Relationships - Please note that we need each member to complete their own screening form in order to complete the review.
Please note that we do not have anyone on staff that is trained to treat substance abuse, addiction or eating disorders. If any of these is a concern, we may not be a good fit.
If you think there is a possibility that you will want to continue seeing the provider after your Lyra covered visits have been exhausted, please provide your insurance information here so we can verify it in advance. If you'd prefer to be discharged at the end of your Lyra coverage, you can select that option under "Primary Insurance Company" below.
Your information will be encrypted.
The purpose of this form is to match your needs and profile to the appropriate provider. It will be reviewed by appropriate staff only. All information submitted will be kept private.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2024 Hush Communications Canada Inc.