INTAKE FORM

*If this is an emergency please call 911. Do to the amount of cases, expect at least 2-3 business days for us to get back with you. Please fill out the following form in order for us to process your information.

Southern Christian serves children and youth 23 years and younger. Parents qualify for this service only if they have children ages 23 and younger. 

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Guardian Type:
Reason for Requesting Services:
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Do you have insurance? If yes, please complete the below information.

Insurance/Fee Information: (if applicable)

Thanks for submitting!