Schools & Organizations Intake Form

School / Organization Information

Name of School or Organization
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website Address

Contact Person

First Name
Last Name
Email Address
Phone Number

Service Needs

Please describe the reason you are seeking services

Is this an organization- or school-wide issue?
YesNo

If not, which area/grade/division is impacted?

Referral Information

How did you hear about Shine Bright Counseling?

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Shine Bright Counseling Required Forms

Please review the following forms before completing this intake:

Open Shine Bright Counseling Required Forms

Please confirm that you have read and agree to the following:

Consent to Treatment and Confidentiality formComplaint Process formTelemental Health Informed Consent formNotice of HIPAA Privacy Policies formConsumer Consent Disclosure form

Electronic Signature (Acknowledgment Required)
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.

Submit Schools & Organizations Intake Form