Licensed Behavioral Health Entity · We Accept Medicaid Insurance
The Don't Look Back Center

Client Intake & Screening Form

Please complete the following information so our team can better understand your needs and connect you with appropriate services.

Basic Information

Housing

Location

Services Needed

Important Privacy Notice

The Don't Look Back Center (TDLBC) is a licensed behavioral health entity. Information submitted through this form may contain sensitive personal information and will be handled according to applicable privacy and confidentiality requirements, including 42 CFR Part 2 and HIPAA. Your information will only be used to connect you with appropriate services and will not be shared without your consent except as required by law.

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