Intake Form

This form is used only for self referral or guardian referrals If you are a youth under the age of 16 please fill out the required guardian information. If you are making a referral from an agency, please email for a referral form. *Please note - if you are having technical issues filling out this form please email

Legal Name(Required)
Guardian/Caregiver Name if under 16
If you are under 16 years old, please provide guardian/caregiver information so the STEP Staff is able to schedule an appointment for you.
Please add your date of birth - year/month/day
Preferred contact method(Required)
Do we have permission to leave a voice message?(Required)