Behavioral Health Provider Intake & Coordination Form

Organization Name *

Program/Service Name (if applicable):

Physical Address(es): *

If physical location is not available or not part of services, please explain.

Service Area (County/Region Served): *

Website:

General Phone: *

General Email:

Core Services Offered: *

Check all that apply

Youth Mental Health Counseling

Adult Mental Health Counseling

Youth Substance Abuse Treatment

Adult Substance Abuse Treatment

Youth Crisis Intervention

Adult Crisis Intervention

Youth Case Management

Adult Case Management

Youth Peer Support

Adult Peer Support

Youth Inpatient Services

Adult Inpatient Services

Youth Outpatient Services

Adult Outpatient Services

Youth Medication Management

Adult Medication Management

Youth Detox Services

Adult Detox Services

Youth Residential Services

Adult Residential Services

School-Based Services

Other

Of the listed services checked above, please provide a brief description *

If "Other" please describe the services offered, not listed above

Specialized Programs offered:

(e.g., trauma-informed care, MAT, Dementia care, co-occurring disorders)

Evidence-Based Practices Used (if applicable):

Age Groups: *

Check all that apply

Children (0-12)

Adolescents (13-17)

Adults (18-64)

Seniors (65+)

Target Populations *

Check all that apply

Veterans

Individuals experiencing homelessness

Justice-involved individuals

Individuals with co-occurring disorders

LGBTQ+

Survivors of trauma/domestic violence

Individuals with disabilities

Other

If "other" please provide additional details

Any Eligibility Requirements or Restrictions: *

Accepted Insurance Types: *

Check all that apply

Medicaid

Medicare

Private Insurance

Sliding Scale

Self Pay

Grant Funded/Free Services

If "Private Insurance" is checked above, please list plans if possible

Average Cost if self-pay:

Financial Assistance Available? *

Yes

No

If "Yes", please describe

Current Capacity Status: *

Open - Accepting New Clients

Limited Availability

Waitlist Only

Not Accepting Referrals

Average Wait Time for Initial Appointment *

Average Wait Time for Ongoing Services *

Id there Crisis/Same-Day Availibility *

Yes

No

If "Yes", Please describe the process

Hours of Operation *

After-Hours Support Available? *

Yes

No

How are referrals accepted? *

Phone

Email

Online Portal

Fax

Walk-In

Required Referral Information *

Typical Response Time to Referral: *

Do you provide referral feedback/updates? *

Yes

No

Public-Facing Contact: *

• Name:
• Title:
• Phone:
• Email:

Direct Referral Contact (“Backdoor” Contact): *

• Name:
• Title:
• Direct Phone:
• Direct Email:
• Best Way to Reach:
• When to Use This Contact (e.g., urgent referrals, system partners only):

Leadership Contact: *

• Name:
• Title:
• Email:

Do you participate in cross-agency coordination efforts? *

Yes

No

If "Yes" Please Describe

Are you open to *

Chek all that apply

Warm handoffs (live coordination between providers)

Shared case coordination (HIPAA-compliant)

Regular system meetings

None of the Above

Do you track outcomes (e.g., follow-through, recidivism)? *

No

No, but open to it

Yes

If yes, what metrics?

If "No, but open to it", What is your biggest concern/barrier?

Approx. Individuals Served Monthly

Common Referral Sources:

Top 3 Service Gaps You See in the Community:

Top 3 Barriers Clients Face in Accessing Care: