Forms

CCS Referraldownload
Birth-to-3 Referraldownload
Referral for CLTSdownload
Sliding Fee Scale Application FormDownload
Release of Information v.8/2023 download

Please call 608-723-6357 or 608-935-2776 prior to completing an intake packet.

Adult Behavioral Health Therapy Intake PacketDownload
Child Age 11-17 Behavioral Health Therapy Intake PacketDownload
Child Younger Than 11 Behavioral Health Therapy Intake PacketDownload
Adult Psychiatric Medication Management PacketDownload
Child Age 11-17 Psychiatric Medication Management PacketDownload

If any form is not listed that you would like to fill out in advance, Please call our office at 608-723-6357. Fax completed forms to 608-723-4417 or bring them into our office. Email us at admin@unifiedservices.org