Request Services

- Access Services
PLEASE COMPLETE THE FORM BELOW AND WE'LL RESPOND
TO YOUR INQUIRY WITHIN 24 HOURS.

If you prefer, please click on the SERVICE REQUEST link above
and open the PDF form. Then, save the form to your desktop, complete it and email it to your preferred Access office
The maximum number of form submissions has been reached. This form is currently not available.
- Date of Referral: REQUIRED Please fill out this field. Please enter a date.
- Person Making Referral REQUIRED Please fill out this field. Please enter valid data.
- Referring Physician/School/Agency/Self REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Client Last Name REQUIRED Please fill out this field. Please enter valid data.
- Client First Name REQUIRED Please fill out this field. Please enter valid data.
- Client Middle Initial Please enter valid data.
- Gender REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- SS# Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Parish or County REQUIRED Please fill out this field. Please enter valid data.
- Client Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Alternate Phone Number (Work/Cell) REQUIRED Please fill out this field. Please enter valid data.
- Insurance Information Please enter valid data.
- Parent/Legal Guardian/Spouse/Next of Kin: NAME REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Client: REQUIRED Please fill out this field. Please enter valid data.
- Phone Number: REQUIRED Please fill out this field. Please enter valid data.
- Alternate Number: Please enter valid data.
- Presenting Concerns/Behaviors REQUIRED Please fill out this field.
- Does the individual (or guardian) know they are being referred to our agency? Yes or No. Please enter valid data.
- How did you hear about Access MHA?
- Additional Information you wish to provide regarding reasons for your visit
- A valid driver's license or state ID, insurance card, and (for children) birth certificate or Court decree of legal custody must be provided at the time of the first appointment
Submit

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Access Client Financial Obligation Notice (Form)

FORM INSTRUCTIONS

When you have been determined to be eligible for services at Access Mental Health Agency (AMHA), a financial assessment is made of your ability to pay.

We ask that you complete our Client Financial Obligations Form and return it to us signed and dated. That form can be opened by CLICKING HERE, then saving the form to your computer. Fill out all blanks on the single page form, sign where indicated, and then save your finished form on your computer.

Once completed, click on the SUBMIT FORM button below, attach your completed form, then email it back to us for review.

Thank you.
~ Access MHA

SUBMIT FORM
Access Mental Health Agency Registration Form

The ACCESS MHA Registration (Intake) Form will need to be completed and sent in to us prior to the provision of any services.

Please CLICK HERE to open the multi-page form, then save the form to your computer. Next, fill out all blanks on the multi-page form, sign where indicated and then save your finished form on your computer.

Once completed, click on the SUBMIT FORM button below, attach your completed form, then email it back to us for review.

Thank you.
~ Access MHA

SUBMIT FORM