Make a Referral

Providers or school counselors, please use this form to refer a client, student, or patient for services.

Provider Information

Please provider the referring provider or school information below.

Referring Provider/Counselor

Referring Company or School

Reason for Referral

Provider Email

Provider Fax Number

Provider Phone Number

Website

Provider Address

Client Patient Information

Client First name

Client Last name

Client Birthday

Month

Day

Year

Client Address

Grade in School or NA

Phone

Best Time to Call

OK to leave a message?

Yes

Guardian Name (if minor)

Guardian Relationship to Minor

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.

Guardianship Paperwork

Primary Insurance Name

Primary Insurance Number

Secondary Insurance Name

Secondary Insurance Number

Substance Abuse Issues?

Yes

If Substance Abuse, Please Give Details

Medications List and Dosage Information (Put NONE if client takes no medication.)

How can we help with this patient? Other Pertinent Info?

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