Request for Information or Initial appointment

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 at this time.

Requestor Name and relationship to person needing services

Contact Email address

Contact Phone number

Preferred contact method if we have further questions:

Email Phone

Medical office direct submision?

Yes No

Referred by:

Seeking services

Type of service

Therapy

Evaluation/Assessment (Testing)

Telehealth ok? Play therapy and most testing would be in-person.

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.

Are there signs of harm/self harm?

Yes No

Name of person for appointment

Date of Birth

For minors, legal custody situation? For Sole or Joint custody, consent from all responsible parties is needed prior to start of services.

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

Best day(s) of week for first appointment:

Any Day

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Mahalo for your contact!

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