Application for L’esprit Services
Today’s Date: ___/___/______
How did you hear about L’esprit:
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Client’s Name:___________________ Date of Birth: _________Age:_____
Social Security No: ___________________________________________
Insurance: _________________________ Policy No:________________
(please provide a copy of insurance card)
Parent/Guardian: ____________________________________________
Address: __________________________________________________
Phone Number: __________________ Work Phone:_________________
Please provide a brief description as to what brought you to L’esprit:
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Primary Physician: _______________________ Phone: ______________________
Has your child ever been treated for mental illness? Y/N
If so, please explain:
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Is your child currently taking medication? Y/N
If so, who is the prescriber? ____________________________________________
What services are you interested in at L’esprit? (circle)
Case management
Therapy
In-home support
Medication management
Mentoring
Parent/Guardian Signature: _________________________ Date: _________________