Janesville Location Paperwork

  • Outpatient Intake Paperwork

    Prior to your/your dependent’s first outpatient appointment, fill out these forms.

  • Day Treatment Intake Paperwork

    These forms must be filled out by parent/legal guardian and client prior to intake assessment for Adolescent Day Treatment.

  • AODA Intake Paperwork

    Prior to your/your dependent’s first appointment, fill out these forms.

  • Day Treatment Referral Form

    If you are a physician, psychiatrist, school staff, or outpatient therapist you can fill out this form to refer a client to our Adolescent Day Treatment program at either location.

  • Day Treatment Survey

    If your child has completed our Adolescent Day Treatment program, we want to hear your feedback on your experience!

  • Medication Form- Hasan Raza

    Clients who receive medication management services through Crossroads Counseling Center will fill out and sign this form upon request and permission from above provider.

  • Release of Information

    Perspective clients and guardians, please fill this form out so that we can communicate with other providers and emergency contacts. Please fill out one form per contact.

    ROI
  • Contact Form

    For any other questions, inquiries, or information, please contact us using this form.

  • Annually Required Documents

    These are documents that all current clients at all locations need to fill out and update ever year.

  • Email/SMS Consent Form

    Current clients can fill out this Email/SMS consent form to allow other forms of communication.