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HELPDevCo

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115 East 13th Street New York, NY 10003 | Phone: 212-400-7000

© 2026 HELP USA. HELP USA is a 501(c)3 tax-exempt organization. EIN 13-3446221.

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Self-Referral Form

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Type of Service Requested:

In-Person Services Virtual Services

Services Requested:

Home+ Services Parenting Journey OVS Application/Information Individual Counseling Group Counseling Family Order of Protection Filing Children's Program (Counseling)

Are you attending any additional services?

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What services?

Case Management Therapy Medication Management Other

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Client Referral for Services

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Family Composition (excluding client, please list ALL children under 18yrs of age):

In Foster Care

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In Foster Care

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Type of Service Requested:

In-Person Services Virtual Services

Services Requested:

Home+ Services Parenting Journey OVS Application/Information Individual Counseling Group Counseling Family Order of Protection Filing Children's Program (Counseling)

Is client attending any additional services?

Yes No

What services?

Case Management Therapy Medication Management Other

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