Referral Form / Consent For Services

I consent for services from Circle Of Hope. I authorize Circle Of Hope. to provide care and coordination of services to me. This may include: Community Based Mental Health Counseling and support for clients suffering from emotional, behavioral, or other mental health issues through our wrap around services that will be implemented by staff. I understand the consent may be withdrawn at anytime.  I have chosen Circle Of Hope to provide me with the following service listed: Case Management, Skill Training & Development, Medication Management, and Counseling.