Care Guidance Intake Form (Confidential)

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Seeking help and accessing mental health care is a journey that we want to walk with you. Let us guide you to understand what is available to you, coordinate your care, and offer resources and recommendations. In our team, we have Care Guides that are clinically trained to help you explore and understand your health insurance, employee assistance programs, student support programs, etc. Let us move past the terrain of mental health stigma and discover healing together.

If you'd like to schedule a Discovery Session to speak with a Care Guide to meet you where you're at and understand what your needs are to help complete this intake form, feel free to email careguidance@selfreclaimed.org with the subject line "Discovery Session" and one of our Care Guides will coordinate a time to virtually meet with you for 10-15 minutes! Otherwise, after you complete this intake form, one of our Care Guides will reach out to you to schedule a Discovery Session to discuss next steps and provide care recommendations/community referrals to best support you.

This intake form takes about 10-15 minutes to complete :).

Email *

Resources

If you or someone you love is currently in crisis, please call 911, or visit your local emergency room. You can also utilize the following resources:

The National Suicide Prevention Lifeline: Call 988 or 1-800-273-8255
Chat: https://suicidepreventionlifeline.org
The Crisis Text Line: Text HOME to 741741 (https://www.crisistextline.org)
Chicago Rape Crisis Hotline: 1-888-293-2080
RAINN Hotline: 1-800-656-HOPE
National Domestic Violence Hotline: 800.799.SAFE (7233)
https://www.thehotline.org/

Confidentiality Disclaimer

Any information regarding your identity is considered Private Health Information (PHI) and will not be released without your authorization/your guardian's authorization (in the case that you are a minor) or unless there is an emergency in which it would be our duty to report to the proper authorities (i.e. child or elderly abuse or any indication of harm to oneself or others).

First & Last Name *

What are your pronouns? *

Phone Number *

How this information can help your Care Guide: so we can reach out to you if you prefer a text/phone call.

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