Lifeworks Behavior Health Service Request

Behavior Health Service Request
In order for us to better assist you accessing treatment services; please fill out the following Behavior Health service request form.
Request Date

MonthDayYear
Client Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Diagnosis*
Preferred Pronouns*
Gender at birth*
Preferred Name*
Race/ethnicity*
Gender Identity*
Spirituality/Religion*
Primary Mode of Communication*
Additional Client Information
YesNo
Please list
YesNo
Please list
YesNo
Please explain
Difficulties Self RegulatingEating DisorderEloping/running away/AWOLProperty DestructionPhysical AggressionSelf-HarmSexual BehaviorVerbal AgressionWithdrawnSuicidal ideation/attemptsHomicidal ideation/attemptsSUD issuesUnable to self-protectIssues as schoolIssues with family membersNone of the above
Comments on behavioral challenges
Any special needs/accommodations to be aware of?*
Likes, hobbies, interests?*
Dislikes?*
Triggers?*

Day/Hours Available*

Behavior Health Service Request