Request for Information

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

Request for Information

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.

Questions with an asterisk (*) are required.

Requestor Name and relationship to person needing services

Self, parent, sibling, etc

Email address

Contact Phone number

Preferred contact method:

Email Phone

Referred by

If a medical referral, please put doctor's name.

Seeking services

Telehealth preferred, when possible?

Yes No

FOR THERAPY REQUESTS, does person show signs of or have thoughts of harm/self-harm?

Yes No

TEST ASSESSMENT (EVALUATION) SERVICES Please check as many as needed.

ADHD

Autism

Learning Difficulty

Neurocognitive (includes Alzheimer's, Dementia)

PTSD

Traumatic Brian Injury (includes Concussion)

Surgery

Other

Concerns

Please describe why you are requesting info or services. If for minor, please put age, and school if this is a school-related request.

Name of person for appointment

Birth Date

This is used to verify insurance.

For minors, legal custody situation? For Joint Custody, we will need consent from all responsible parties to schedule.

Two-parent household Sole custody Joint custody

Other medical insurance

We may be able to accept some with pre-approval. Please also put secondary insurance, if any

Non-Insurance customers or those with insurances we cannot accept will be charged full rate. Please ask us for a Good Faith Estimate of charges based on what details you give us.

Best day(s) of week for first appointment: First appointments are scheduled on weekdays. Closed on Sundays and federal holidays.

Mon

Tue

Wed

Thu

Fri

Any Day

How did you hear about us? Please check all that apply.

Internet search

Medical insurance provider search

My doctor

School counselor

Word of Mouth

Other

Mahalo for your interest in us!

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