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LSI’s Mental Health Program for Uninsured and Underinsured Youth

LSI’s Mental Health Program for Uninsured and Underinsured YouthFebruary 18, 2021February 25, 2022

LSI’s Mental Health Program for Uninsured and Underinsured Youth is available for uninsured and underinsured children and teens in Polk County, at no cost to their families.

Who is Eligible?

Polk County families with children or teens under the age of 18
Families with no form of insurance
Children with a designated Serious Emotional Disturbance from their physician or LSI therapist.
We provide service to individuals who have a co-pay and deductibles that are at 500% poverty.

How to Get Started

Fill out the intake form below or
Call 888.457.4692
Families can enroll in this program on their own or a family’s caseworker can enroll for them.

Intake Form

Name

Call Central Intake at 888-457-4692 with questions

Client Information

First Name *

Middle Name

Last Name *

Date of birth *

MM/DD/YYYY

Gender or Gender Identity *

Male

Female

Personal Pronouns

Age *

School (if applicable)

Reason for Services

Race

Black (African American)

Asian

Caucasian

Native American

Pacific Islander

Not Provided

Ethnicity

Asian (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Hispanic or Latino

Native American or Alaska Native (Not Hispanic)

Two or More Races

Two or More Races (Not Hispanic or Latino)

White (Not Hispanic or Latino)

Not Provided

Primary Language

Religion

Program Type

Program

Mental Health Therapy Services (re)Assessment Only BHIS - Behavioral Health Intervention (Only covered by IA Medicaid)

Parent Guardian Information

Parent/Guardian Name

Relationship to Client

Marital Status

Primary Custody

If biological parents are not married or child is in foster care/placement *bring custody agreement/court order stating who has leagal guardianship to 1st meeting.*

Current Address *

City *

State *

Zip *

County of Settlement *

How does client or parent/guardian prefer to be contacted? *

Phone

Email

Text

Would client or parent/guardian like appointment reminders?

Yes

No

Unknown

Referral Information

Who referred you to Lutheran Services of Iowa? OR Please give your information if you are the referral source.

Referral Date

Referral Name

Referral Phone

Email

Organization

State

Source

What made you contact LSI today?

Billboard Brochure Current LSI Client in Another Program Email Event Existing Relationship Family Member was/is LSI Client Internet Search Mail None Other

Form Completed By

ELCA PARTNERSHIP

LSI is an affiliated social ministry partner of the Iowa congregations of the ELCA (Evangelical Lutheran Church in America) and a member of LSA (Lutheran Services in America). We proudly serve people of all ages, abilities, religions, sexes, gender identities, national origins, ethnicities, races, and sexual orientations.

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