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Girl Scouts of Orange County

Troup Number/Juliette: *

This form was completed by: *

Position/Title: *

Email Address *

Phone Number *

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Name of Initiator *

Relationship to Client: *

Full Name of Client *

Date of Birth (D.O.B.) * +

Age of Client *

Gender of Client *

Phone Number *

Alternative Number

Email Address

Do we have permission to leave a message on these numbers? *

Yes

No

Presenting Issue (exactly as reported): *

Type of Counseling Requested: *

Gender Preference of Counselor: *

Male

Female

No Preference

Not Applicable

Language Preference of Client: *

Please note that your therapeutic services at OMID will be based on a sliding scale and determined by the family’s income after the 8 sessions paid for by the Girl Scouts of Orange County have been completed.

Please initial to confirm that the potential client already discussed this matter with the client or the guardian, and they are interested to hear from us

Has the Client had any suicidal or homicidal thoughts or concerns? *

Yes

No

If "yes," ACTION TAKEN

Please seek support at the following agencies designed to manage crisis 24 hours a day 7-days a week:
• Orange County Crisis/Suicide Prevention Hotline: (877) 7-CRISIS or (877) 727-4747
• Crisis Line for People with Disabilities: (800) 426-4263
• Domestic Violence Hotline: (800) 799-7299
• Rape Crisis Hotline: (714) 957-2737
• Sexual Assault Victims Services: (714) 834-4317

Acknowledgment that the information above was received

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Assigned Case Number (OMID use)