Government Agencies | TeleHelp247.org

top of page

Home
Sign Up Now
About
- Meet Our Team
Government Agencies
Students
- Student Enrollment form
Services
Wellness Wednesdays
- Blog
Press Releases
Talk It Out

LLÁMENOS AHORA: 888-247-5767

TeleHelp24/7 partners with government agencies to provide trauma-informed counseling, behavioral health support, referral services, crisis intervention, and case coordination for individuals and families facing emotional, behavioral, legal, educational, and substance use challenges.

ChatGPT Image May 12, 2026 at 07_33_02 AM.png

Demographic Information

Client Name *

DOB:*

Address

Age

Contact Number*

SSN:

Does the client have insurance*

Yes

No

Gender:

Ethnicity

Marital Status:

Highest Completed Grade Level:

Employment Status:

Legal Status (# of arrest in past 30days) :

Legal Guardian Name (if applicable):

Relationship:

Email

Insurance Information

Insurance Name or Responsible Party*

Group Number

Member ID Number

Referral Source

Agency*

Name of Referrer*

Referrer Contact Number

Referrer Email *

Reason For Referral (check all that apply)

Behavior/Conduct

Emotional Mental Illness

Employment Instability

Legal/Probation/Court Mandated .

Social/Interpersonal

Challenges

At Risk

Substance Use/Abuse

Educational Instability

Service Requested (check all that apply)

Individual Counseling

Family Counseling

Group Supports

Counseling .

Grief and Loss

Counseling

Substance Use

Anger Management

Sexual Abuse

Counseling

Peer Counseling

Symptoms and Behaviors of Risk: (check all that apply)

Anxiety/Panic

Adjustment Challenges

Depressed Mood

Psychotic Features

Suicidal Ideations/

Attempts

Homicidal Ideations/

Attempts

Isolative Behaviors

Hyperactive

Manic Mood

Impulsivity

Physical Aggression

Verbal Misconduct

Unlawful Activity

Self-Care Deficit

Social Withdrawal

Obsessions/

Compulsions

Physical Pain/

Discomfort

Changes In Sleeping Pattern

Changes In Appetite

Please Describe the Presenting Problem

Contáctanos HOY

bottom of page