Our IntakeQ client portal system requires cookies to be enabled to allow clients to access forms online.

PLEASE NOTE: Ongoing clients and referrals from Madison County Physicians have priority for Attention Assessments.

We have a wait list of @ 2 months for other Attention Assessments. 

To begin the process of becoming a client, 

COMPLETE ONE OF THE TWO FORMS  BELOW

After you complete and submit the forms, you will be taken to the next step.

After clicking “submit” please wait until directed to another web-page.

Please use the NAME of the Person Who will be the Actual CLIENT!!!

for ADULTS:     Click Here

for a MINOR CHILD** or a Dependent Adult:     Click Here

**PLEASE NOTE: We will need to have copies of ALL custody paperwork BEFORE we can schedule a minor child for treatment

If you have difficulty completing or understanding the forms, please call 740-845-8652, select the “new client” option and ask for assistance.

 

Other Information:

Review our Privacy Policies Here:   Click Here

Review our Complaint Procedures Here:  Click Here