CHART Initial Inquiry Form

CHART is working to help families with the extreme costs of residential treatment through CHART RTC grants. Currently we are only able to qualify families who live in Arizona or Colorado who have adopted children 9 to 13 years old with a major depressive disorder or mood disorder diagnosis. Click here to learn about CHART's funding procedure. Download a PDF of the form here.

Initial Inquiry

Date:
Client #:
Referred by:

Students Name:
Date of Birth:
Present Grade Level:
School:
Counselor:
Special Needs: LD____ EH____ G/T_______ Other:
Diagnosis:
Medications:
Therapist(s):
Phone:
Medical Doctor:
Phone:

STUDENT’S CONTACT INFO
Student lives with: (full names)
Mailing Address:
Email Address:
Home Phone:
Work Phone:
Cell Phone:
Fax:
NAME OF PERSON MAKING INQUIRY:
Relationship to person making inquiry:

OTHER PARENT
Name:
Mailing Address:
Email Address:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Insurance Company:
Responsible Party:

MORE STUDENT INFO
Academic Interests:

Extra-curricular activities:

Grades:

Tests & Scores:

Character/citizenship:

Athletic activities:

COMMENTS