Request Intervention

Please fill out the form completely, then press 'submit' so that our team can get to know more about your situation before calling you back. If there is an immediacy to the crisis you face - your loved one presenting as a threat to themselves or others, please dial 911 now.

All information submitted will remain strictly confidential.

A Little About You

Your Name
Relationship to Friend
Email
Home Phone
Cell Phone
Address
City
StateYour state's 2-letter abbreviation.
ZipYour 5 digit zip.
Intervention needed? Yes   No  
How did you hear about our work?
 

About Your Friend

Friend's First Name
Marital Status
ChildrenNumber of children under 18
The individual I am concerned about is having a problem with:
  Alcohol
Drugs
Debt
Gambling
Sex
Internet
Disordered Eating
Other
Has your friend had prior treatment for this or any other problem?
  Yes   No  
If yes, specify:
Is your friend currently under the care of:
  Psychiatrist
Therapist/Counselor
Psychologist
None
In the past year, has your friend:
  Talked of suicide
Planned suicide
Attempted suicide
Unknown
Does your friend have any eating disorders?
  Anorexia
Bulimia
Other
None
In the past year, has your friend:
  Expressed intent to harm another
Engaged in threatening behavior
Harmed another
Received a notice of a restraining order
Other
When we contact you, we will ask you about your payment preferences and/or insurance information if applicable.


Intervention Specialists and our treatment professionals have no affiliation with any treatment center or facility. NYC's Intervention Specialists is not a referral service and adheres to the AISCB Code of Ethics. Intervention Specialists profits in no way from your choice of treatment facilities either directly or indirectly.