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Referral Form

Intake Form
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Referral Source

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.

Name (Person Giving Referral)
Client Personal Information
Client Name
Gender*
Race*
Student Status*
Is an interpreter needed*
PARENT/GUARDIAN INFORMATION
(If Client is under age 18, the below information is required)
Parent/Legal Guardian Name
Address
Emergency Contact Information
Is an interpreter needed?*
Presenting Concerns
Is the Client Currently Enrolled with Another Mental Health Provider?*
Is the Client Currently Taking Mental Health Medications?*

1810 E 10th street Alamogordo NM 88310

575-446-1125
info@horizonpath.com