Mental Health Services Referral Form

Child/Youth's Name

First Last

Date of Birth

Gender

Male

Female

Other

Address

Street Address City State / Province / Region ZIP / Postal Code

Legal Guardian's Name

First Last

Phone

Can a message be left?

Yes

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Date of Referral

Mental Health Diagnosis

Signature

Insurance Provider

Medicaid

Commercial (Out of Network Only)

If Commercial, which plan?

Commercial/Medicaid Number

Intake Completed

Unable to contact Guardian

Guardian declined services

Staff Processing Referral

WHERE TEENS AND FAMILIES HEAL TOGETHER