EL PUEBLO INTAKE FORM

***If at any time there is a physical or mental health emergency, call 911 or go to the nearest emergency room. Be prepared to give your address to the operator. For Domestic Violence call Center for Violence Prevention at +1 (601) 932-4198 (Spanish speaking staff are available).

SCSCY can currently see counseling clients in the following condition under a grant:

A victim of crime that they want to work on in therapy
A child/youth 0-23, or
A caregiver of a child/youth 0-23
Must have zoom added to phone or a plan to go to El Pueblo for sessions
Must know if there is potential for immigration support

El Pueblo Intake Form

Date:

Name of person submitting form:

Email of person submitting form:

Phone number of person submitting form:

Name of person wanting counseling:

Age of person wanting counseling:

Languages person wanting counseling speaks:

Birthday of person wanting counseling:

If so, what is the insurance and number:

Guardian of person wanting counseling:

Languages guardian speaks:

Self/Guardian Address:

Self/Guardian Phone Number:

Self/Guardian Email Address:

What days and times is the person able to take a call to schedule an appointment?

What are the days and times you are NOT able to make an appointment. (Limiting the hours could delay when the person is able to be seen)

Additional Information: