NYAP Behavioral Health Referral Form

NYAP Behavioral Health Services

Referral Form
Referral Source Contact Name*

First NameLast Name
Referral Agency
Doctor's office, county department, etc.
Referral's Contact Email*
example@example.com
Are you referring for yourself or on behalf of someone else?*

MyselfMy child/youthSomeone Else
Name of person seeking services*

First NameLast Name
Date of Birth*

MonthDayYear
Date
If you are referring on behalf of a youth, what is their Parent or Caregiver's name and relation?*

First NameLast NameRelationship
Your email or the Caregiver's Email*
example@example.com
Your Phone Number or Caregiver's Phone Number*

Area CodePhone Number
Address of person seeking services

Street Address

Street Address 2

CityState

Zip Code
State:*
If Ohio, what is the person's County of Residence?*
What concerns are you hoping to address with NYAP services?*
What type of services you are interested in?

Bridges to SuccessCommunity Based Emergency Stabilization CareExternal or BH RespiteFunctional Family TherapyIntensive Home-Based or In-Home ServicesOut-Patient Mental HealthParent Education/DevelopmentPASS-PSB or Healthy Ways for youth with problematic sexual behaviorsSchool Based CounselingSubstance Use Disorder TreatmentTransition Services ProgramWraparoundBrief Strategic Family Therapy (BSFT)Neurosequential Model of Therapeutics (NMT) Brain MapI am not sureOther
How did you hear about NYAP?*

Social MediaGoogle SearchWebsiteParticipant of other NYAP program(s)Friend ReferralDrive byOther
Please verify that you are human*
Click Submit Below to Complete

Once completed, your referral will be processed by the NYAP office nearest you. Most referrals will be processed and contacted within 2 BUSINESS DAYS.
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NYAP Behavioral Health Services

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