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Behavioral Health Referral Intake

Please complete the following form to make a referral to our Behavioral Health programs. Someone from our agency will contact you shortly.

Please select a referral type.
Please select a language preference.
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Please select Team/Worker gender preference.
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Please select housing.
Please select member race.
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Please select ethnicity.
Please select member gender.
Please indicate if an interpreter is needed.

Member Information

Please enter member's name.
/ / Please enter member's date of birth.
Please enter Parent or Guardian name.
Please enter Parent or Guardian phone number.
Please enter Emergency Contact name.
Please enter Emergency Contact phone number.
Please enter member's address.
Please select Primary Insurance.
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General Information

Please enter the reason for referral.
Please enter the past or current behavioral health services.
Please indicate if member has a diagnosis.
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Please indicate if the youth is on any psychotropic medication.
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Are there any pets in the home?
Are there any weapons in the home?
Are there any active restraining orders?

Household Members

Please list other household members, their age, and relation.

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School Information

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Referral Source Information

Please include your name and contact information.

Please enter Referral Source Full Name.
Please enter Referral Source Address.
Please enter Referral Source Email.
Please enter Referral Source Job Title.
Please enter Referral Source Phone.
Please enter Referral Source Fax Number.