Please select the service you are interested in:
If you have sole legal custody, you will be required to submit documentation before receiving services. If you have joint custody, any and all legal guardians with custody need to be present at the initial clinic visit. Please note that we do not do forensic evaluations.
Has your child (or yourself if over 18) ever been hospitalized for mental health issues? If yes, please provide the date(s)
Does your child (or yourself if over 18) currently have a psychiatrist, psychologist and/or therapist?
If yes, please enter the names of the current providers:
i.e. physical assault, broken items, punched a hole in the wall
Please describe the circumstances and most recent epsiode of violence
Is your child having serious problems at school either academically or socially?
We do specific treatment protocols at our agency, and often require therapy to be done at our agency. If you have another therapist and/or psychiatrist , would you be willing to leave your current therapist and/or psychiatrist for 6 months to have a treatment course at BACA?*
Do you or your child currently use any illegal (marijuana, cocaine, ecstasy, etc) or legal (tobacco, alcohol, medical marijuana) substances of abuse?
If yes, list substances and frequency of use:
Thank you! You're form has been received and our administrative staff will be contacting you to follow up.