Submit A Referral

Submit an electronic form.

Please fill out the form below to start the process for intake and treatment.

Fields marked with an asterisk (*) are required.

Type of Service Needed*

Referring Agency/Person Info:

Referring Agency *

Date of Referral *

Referring Person *

Title of Referring Person *

Email *

Phone Number *

Consumer/Client Info:

Consumer First Name *

Consumer Last Name *

Date of Birth *

Age *

Race *

Gender *

Address *

Phone number *

Parent/Guardian Name *

Insurance Info:

Is consumer covered by insurance? *YesNoUnsure

Primary Insurance MedicaidHealth ChoiceIPRSSelf PayOther

Is consumer adjudicated? *YesNoUnsure

Is consumer on probation? *YesNoUnsure

Treatment Recommendations

Signature of Person Completing Form

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