Request for Information or Initial appointment

All requests are kept secure and confidential. We are experiencing a high volume of calls/requests, but we will be in touch as soon as possible.

Please correct the errors described below.

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

Requestor Name and relationship to person needing services

Contact Email address

Contact Phone number

Preferred contact method:

Email Phone

Referred by:

Seeking services

Telehealth preferred, when possible?

Yes No

For Therapy: Please describe concerns.

Are there signs of harm/self harm?

Yes No

Evaluation/Assessment request: Please describe concerns and/or reason for assessment request

Includes Educational, Neurocognitive, Surgery, etc

Name of person for appointment

Date of Birth

For minors, legal custody situation? For Sole or Joint, consent from all responsible parties may be needed

No custody issues Sole custody Joint custody

Primary Medical Insurance

If not listed here, we may not be able to accept. For Testing/Assessment, please check with your plan for any benefits, some concerns may not be covered.

Best day(s) of week for first appointment:

Any Day

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Mahalo for your interest!

Your information will be encrypted.

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

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