MU PSC Request for Services - Youth

If you are requesting services on behalf of your under 18 child, then please fill out the following information about your child (unless otherwise indicated).

[Office staff] Client Number:

[Jenna/Jaclyn] Clinician's last name:

[Clinic staff only] Name of office support assistant completing this form:

Today's Date:

* must provide value

M-D-Y

Client's Legal Last Name:

* must provide value

Client's Legal First Name:

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Client's Preferred Name (if different from above):

Gender:

Pronouns:

Race/Ethnicity:

Age:

Date of Birth:

* must provide value

M-D-Y

If you are requesting services for your under 18 child, please type your name and your relationship to the child:

* must provide value

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What is the best phone number to contact you or leave a voicemail? (if requesting services for your under 18 child, please put your phone number):

* must provide value

What is the best email for us to use when contacting you about an appointment? (if requesting services for under 18 child, please put your own email):

* must provide value

Local Street Address:

* must provide value

City (for example, Columbia):

* must provide value

County (for example, Boone):

* must provide value

State:

* must provide value

Zip Code:

* must provide value

What is your current employment status? (If you are requesting services on behalf of your under 18 child, please put down your employment information).

Are you a student? (If requesting services on behalf of your under 18 child, please put their student status.)

Yes

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Have you already graduated from high school or earned high school equivalency? (If requesting services on behalf of your under 18 child, please put their graduation status.)

Yes

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Please describe the concerns that you (or your child) need help with.

* must provide value

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Are you (or your child) currently experiencing any thoughts of suicide or self-harm?

* must provide value

Yes

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Please briefly describe these thoughts:

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Emergency Contacts & Crisis Resources

If you feel like you cannot keep yourself or others safe, please seek emergency help immediately by calling 911, going to your local emergency room, or using one of the following resources. We offer the following resources in case of emergency:

Organization	Phone Number	Text Number	24/7 Crisis Services?
MU Counseling Center	573-882-6601		Yes
Missouri Crisis Line	1-888-761-4357	HAND to 839-869	Yes
Trans Peer Support Hotline	877-565-8860		Yes
Trevor Project (LGBTQ youth)	866-488-7386	START to 678-678	Yes
National Suicide Prevention Hotline	1-800-273-8255	HOME to 741-741	Yes
Deaf Crisis Line	321-800-3321		Yes
Burrell Behavioral Health Walk-in Clinic (3401 Berrywood Dr. Columbia, MO)	573-777-8300		Monday-Friday, 8am to 5pm
Missouri Psychiatric Center (3 Hospital Dr. Columbia, MO)	573-884-1255		Yes

How did you hear about us (e.g., insurance company, website)?

Are you or your child currently involved in any legal situation, such as a court case, custody battle, or needing a child abuse investigation?

* must provide value

Yes

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What is your insurance company and plan? (If none, put none).

* must provide value

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