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The information collected in this form will be used to help our CARE Program Family Navigators provide clients and families with information about the mental health providers/resources available in their area. Upon completion of this intake form, the CARE Program will send a confirmation email to both the referral source, as well as the referred client's legal guardian. One of our Family Navigators will then contact the referred client's family to schedule and complete an intake appointment. We are doing our best to schedule these intake appointments in a timely manner. Finding mental health services that may have the ability to accommodate a client's individual needs can sometimes be a lengthy and challenging process. We ask for patience and grace as we manage a high volume of referrals while navigating our complex mental health system.

The information in this form is confidential and protected by HIPAA privacy rules.

You are welcome to leave any of the questions unanswered. You may also enter "I don't know" or "N/A" as responses if needed.

Disclaimer of Warranties and Liabilities

The CARE Program, facilitated by the Indiana Chapter of the American Academy of Pediatrics ("INAAP"), provides information on mental health care services available in the state of Indiana and aims to connect participants to resources available in their area. However, inclusion of a physician, medical practice, counselor, or other mental health care provider is not and does not imply endorsement by INAAP or the CARE Program. It is still the sole responsibility of the participant or their legal guardian to determine whether a listed provider fits the needs of the participant.  Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care plan. NO MEDICAL ADVICE IS BEING PROVIDED THROUGH THIS SERVICE. 

INAAP makes reasonable efforts to keep the information used as part of this program accurate. However, because information changes quickly and can become out of date, INAAP makes no representations or warranties of any nature with respect to the information obtained through program. 

INAAP shall not be liable to you or others for any decision made or action taken by you in reliance on the information obtained from this service. Please indicate your agreement with the terms and conditions set forth above by clicking below on the button labeled "Accept."
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