Request a Mental Health Assessment | Admissions

24/7 Assessments

Authorization to Release Protected Health Information

If you are actively suicidal or homicidal please call 911 or the national suicide hotline at 1-800-273-8255 or seek treatment at your nearest Emergency Room.

Name*
First Last
Phone
Email*
Check-In Time*
Date*
MM slash DD slash YYYY
Why are you seeking an assessment?*
Please confirm the following*
- I have read and agreed to the Disclaimer.
- I have read and agreed to the Privacy Policy.
- I understand for Hickory Trail Hospital to hold my reservation time, I must print & fill out the forms provided above, & bring them with me to my appointment.
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