Client Assignment | Improving Lives Counseling Services

Client First Name*

First 5 Letters of Client Last Name*

TH ID if Known or Phone Number from NCF Form*

Add or Remove?*

Reason for Removal*

If you are discharging your client, DO NOT FILL OUT THIS FORM. Please submit the CDC Request Form with Discharge option selected instead.

TH ID No.*

Who was the client transferred to*

Responded on NCF?*

Reason for Adding*

Other - Reason for Removal*

Clinician Making the Request*

Clinician Email Address*

Verification*

I verify that I have already checked TH to see if I have been added

I verify that I have expanded the letters for both first name and last name to see if I have already been added to this chart before submitting this form.

Client Assignment Request