Make a Referral

Providers or School Counselors, Please use this form to refer a client/students/patient for services. 

Provider and School Referral Form

Provider Information below.
If this is a school, please enter school, school counselor information here.
Client Patient Information below.
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NOTE: If a minor has been displaced, under the care of DSS or a court ordered custody situation has been established, please upload guardianship paperwork with this referral. You may submit this after the fact, but before care can be established. 
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Substance Abuse Issues?
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