This form may collect protected health information. Please provide only the information necessary for Alliance Behavioral Health Integrated, PLLC Clinic to review this request, coordinate follow-up, verify contact information, and determine the appropriate next steps for non-emergency appointment requests and support planning only. It is not monitored as a 24/7 crisis line and should not be used for emergencies.

Information submitted through this form may be used, disclosed, stored, and maintained in accordance with Alliance Behavioral Health Integrated, PLLC Clinic’s Privacy Policy / Notice of Privacy Practices and Medical Data Policy.

Need Help Now?

If you or someone else is in immediate danger, call 911 or go to the nearest emergency room.

If you are experiencing suicidal thoughts, a mental health crisis, substance-related crisis, or emotional distress, call or text 988 for crisis support.

Alliance Behavioral Health Integrated, PLLC Clinic is not a 24/7 emergency response provider.

DO NOT WAIT FOR A RESPONSE FROM THIS FORM IF THERE IS IMMEDIATE DANGER, URGENT SAFETY RISK, OVERDOSE, SEVERE CONFUSION, OR RISK OR HARM TO SELF OR OTHERS.

Patient Information

Person Completing This Form

Emergency Contact

Reason for Request

Current Safety Status

IMPORTANT: If the patient is in immediate danger, cannot stay safe, has attempted suicide, may overdose, is experiencing severe confusion, or may harm self or others, call 911, call or text 988, or go to the nearest emergency room.

Minor Patient Information, (If Applicable)

If yes:

Requested Next Step

Uploads (optional)

Consent, Authorization & Acknowledgment

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge.

I authorize Alliance Behavioral Health Integrated, PLLC Clinic to receive, review, use, store, and maintain the information submitted through this form for request review, appointment coordination, crisis prevention support planning, behavioral health follow-up, treatment coordination, insurance verification when applicable, documentation, and related healthcare operations.

If I am submitting this form on behalf of another person, I confirm that I am authorized to do so and that I have obtained the patient’s consent, or the consent of the patient’s parent, legal guardian, or authorized representative when applicable, to share this information with Alliance Behavioral Health Integrated, PLLC Clinic.

I understand that this form may include protected health information and that I should submit only the minimum necessary information needed for this request.

I understand that if the request involves substance use disorder treatment information, addiction treatment information, or MAT-related information, additional federal and state confidentiality protections may apply, and additional authorization may be required before certain information can be disclosed.

I understand that submission of this form does not guarantee acceptance into services, confirm an appointment, establish a provider-patient relationship, or create a 24/7 crisis response obligation.

I understand that this form is for non-emergency crisis prevention support planning only and is not monitored as a 24/7 crisis line.

Electronic Signature & Electronic Record Consent

By completing and submitting this form, I agree to use an electronic signature for this request. I understand and agree that my electronic signature is intended to have the same effect as a handwritten signature to the fullest extent permitted by law.

I consent to Alliance Behavioral Health Integrated, PLLC Clinic collecting, receiving, storing, and maintaining this form, my electronic signature, submission details, uploaded documents, and related request information in electronic format.

I understand that electronic records may be stored in secure electronic systems used by Alliance Behavioral Health Integrated, PLLC Clinic and/or its authorized technology vendors. I understand that Alliance Behavioral Health Integrated, PLLC Clinic uses reasonable safeguards designed to protect electronic protected health information in accordance with applicable privacy and security requirements.