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Intake Face Sheet

Contact Us
Referral Form
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Client Information

Please complete the form below for yourself or someone you believe may benefit from our services. Once submitted, a member of our team will contact you to schedule an interview and determine eligibility. If you have any questions or concerns, feel free to reach out to us.

Please upload a picture of your (or the guardian's) I.D.*
Please upload a picture of your insurance card front and back.*
Marital Status*
Gender*
Student Status*
Race*
Do you need an interpreter?*
Have you previously received or currently receiving mental health services? *
PARENT/GUARDIAN INFORMATION
(If Client is under age 18, the below information is required)
Parent/Legal Guardian Name
Address
Emergency Contact Information
1810 E 10th street Alamogordo NM 88310
575-446-1125
info@horizonpath.com