New Client Appointment Request

Emergency Assistance If this is an emergency, call 911!

Hawaii CARES provides a team of professionals 24/7 to help in a mental health crisis. ALL ISLANDS: 1-800-753-6879

*We do not provide court-related services or emotional support animal requests.

New or returning client?

New Returning

Requestor Name and relationship to person needing services

Contact Email address

Contact Phone number

Referred by:

Seeking services

Type of service

Therapy

Evaluation/Assessment (Testing)

Purpose

For my own mental health

Medical treatment

Academic assistance

Employment requirement

Legal use

State Disability benefits determination

Other

Please add details in box below.

For evaluations, will you need any documents/letters other than the final report?

None Letter(s) Form completion Other

Appointment style preference: Play therapy sessions are in-person. Most testing is in-person. Ask us about tele-testing for neighbor island requests.

Telehealth In-person Any

Are there signs of harm/self harm? If Yes, please add below last known date of incidient, or if ongoing.

Yes No

Please describe behavioral concerns and/or reason for request.

For Testing (includes Educational, Neurocognitive, Medical, etc), please also list any prior evaluation with result, if any, and details such as Attention, Memory problems, Shyness, Aggression, etc with date or age started noticing.

Name of person for appointment

Date of Birth

Age 18+? Direct email for registration forms is required, if different from above.

Requestor email will be used if requesting for own child/legal dependent.

For minors, school attending?

For Autism Spectrum evaluations, we have limited number of appointments. If we do not have an opening in the next two months, would you like to be on a waitlist? These are normally referrals by PCP to confirm.

Yes No

For minors, legal medical custody situation? For Sole or Joint custody, consent from all responsible parties is needed prior to start of services. Please have ready a copy of agreement so we can verify our responsibility.

Lives with parent(s), no custody arrangements Sole custody Joint custody

Seondary insurance, if any:

No insurance coverage or self-pay? Ask us for a Good Faith Estimate. GFEs are for known costs at time of creation. For evaluations, a full list of services will be given, but if you have medical insurance that the clinician is in-network with, some of the costs may be covered, please check with your plan.

Send me a Good Faith Estimate! No, do not need one at this time.

Best day(s) of week for first appointment:

Any Day

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Best times

Any time

8a -11a

12p - 3p

2p - 5p

Mahalo for your contact!

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