Behavioral Health Services Clinical Intake Form

Intake Forms request a great deal of data and take time and care to fill out properly.

We ask clients to download the form by right clicking on the link listed below. Once downloaded, fill out the form electronically by using Adobe Acrobat or print the form and fill it out by hand.
Once complete, e-mail the form to, scan and fax the form to (203)202-7655, or bring the form to your first
appointment at The Southfield Center
Behavioral Clinical Intake Form