Interested in Counseling? Start here First Name * Potential Clients name Last Name * Email * Address * Home Address City * State * Zip Code * Client's age * Client's Date of Birth * MM DD YYYY Cellphone Number * (###) ### #### Home Phone Number (###) ### #### Client Sex * Male Female Transgender FtM Transgender MtF Nonbinary Relationship Status * Single Married Partnered Divorced Widowed Emergency Contact * Name and Phone Number Name and Relation of Person Filling out this Form * Educational Information Please complete if the referring client is a student Student * Yes No We offer in-school counseling for students at Milford Public Schools. If looking for in-school counseling, please indicate grade and school the student attends. For Milford Public School students only Insurance Information Card Number/Subscriber Number * Insurance Company * Name of Insurance Subscriber * Please also include their address if different from client Subscriber Relationship to Client * Subscriber Date of Birth * MM DD YYYY Subscriber's Employer Copayment Current Concerns and Additional information This information will help us provide the best fit regarding a provider for yourself or the referring client. What are your or the client's current concerns and goals for therapy? * Please be as detailed as possible so we can match you with the therapist best suited for your needs. Telehealth or in-person? * Telehealth only Telehealth preferred Either telehealth or in-person/no preference In-person preferred In-person only What is the best way to contact you? * Please choose all that apply Phone call Text message Email What type of service best describes what you are looking for? * Individual Therapy Play/Art Therapy Substance Abuse Counseling Substance Abuse and/or Mental Health Evaluation Eating Disorder Therapy Sex Offender Specific Treatment Group Therapy Couples Therapy Family Therapy Other Availability for appointment times * Open Availability Morning Afternoon After School Evening after 5 PM Weekends In School How were you referred to Community Impact? * Friend School Insurance Company Police Department DCF Google Search Primary Care Doctor Milford Regional Medical Center Probation Regional Substance Navigation Services Other