Please indicate who you are seeking services for. Please indicate who you are seeking services for. Seeking services for yourself. Seeking services for a friend or family member. I'm a provider trying to refer someone.

Your Name

Your Name

Your Name

Your Credential

Your Agency

Your Method of Contact

Your Phone Number

Your Phone Number

Your Email Address

Your Email Address

Your County

Potential Client Name

Potential Client Name

Potential Client Phone Number

Potential Client Email Address

Potential Client’s County

Potential Client’s County

Name of your mental health provider/therapist/etc.

Provider Phone

Provider Fax

Name of Potential client’s mental health provider/therapist/etc.

Provider Phone

Provider Fax

Do you have services/a worker elsewhere? Do you have services/a worker elsewhere? Yes No

Details

Does the potential client have services/a worker elsewhere? Does the potential client have services/a worker elsewhere? Yes No

Details

Are you a current or former Guild client? Are you a current or former Guild client? Yes No Not sure

Is this person a current or former Guild client? Is this person a current or former Guild client? Yes No Not sure

Is this person a current or former Guild client? Is this person a current or former Guild client? Yes No Not sure

What type of help are you looking for? What services are you interested in? What type of help are you looking for? What services are you interested in? Residential services / IRTS/Crisis Drop-in member center / Community Support Program Mental health services/case management / BHH, TCM, ACT Integrated employment services Integrated employment services Donations to Guild / Volunteering with Guild Other (describe what you are looking for below)

What type of help is the potential client looking for? What services are they interested in? What type of help is the potential client looking for? What services are they interested in? Residential services / IRTS/Crisis Drop-in member center / Community Support Program Mental health services/case management / BHH, TCM, ACT Integrated employment services Integrated employment services Donations to Guild / Volunteering with Guild Other (describe what you are looking for below)

What type of help is the potential client looking for? What services are they interested in? What type of help is the potential client looking for? What services are they interested in? Residential services / IRTS/Crisis Drop-in member center / Community Support Program Mental health services/case management / BHH, TCM, ACT Integrated employment services Integrated employment services Donations to Guild / Volunteering with Guild Other (describe what you are looking for below)

Any other information you would like to provide?

Any other information you would like to provide?

Any other information you would like to provide?