Helping 2 Overcome Systems LLC

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Requesting Services

Who is filling out this form?

Self

Parent/Guardian

Other Entity

Referral's Name (if not the client)

Relationship to Client

Client's First name

Client's Last name

Do you give permission to receive text messages for scheduling purposes if you have shared your cell phone number below?

Yes

Phone

What type of phone is this?

Cell

Home

Address

Which services are you interested in? (Select all that apply)

If needed, you can print a copy of this record before submitting the form. You can also ask your H2O provider for a copy.

What does this form do?

This form helps us understand your needs so we can connect you with the right team as quickly as possible. At H2O, we’re committed to providing a full range of prevention, mental health, and substance use treatment services across the state. By filling out this form, you’re helping us take the guesswork out of matching you with the best support possible.

Who should complete the form?

This form can be completed by anyone in need of services or by someone submitting on their behalf (such as a parent, guardian, legal caretaker, health care provider, or insurance provider). Please note that we may request any necessary legal documentation to proceed.

Next Steps

After submitting the Request for Services form, our Administration Team will work with you to take the next steps. We’ll consider where you live, your availability, and your specific needs to connect you with the right professional who can provide the support you’re looking for. Please note that we will require proof of insurance and other documents to be signed before scheduling an initial intake appointment. Together, we’ll ensure you’re on the right path to care.