WestCare Adolescent Services: Referral Form

Adolescent Services Referral Form

Outpatient Alcohol / Drug Treatment for Youth Ages 12 - 17 in Kings County
Please complete this application and submit all requested information. All personal data submitted will remain confidential.

This form takes just a few minutes and may take 1 - 3 business days to be processed. Don’t forget to click submit!

No Kings County resident will be turned away due to their inability to pay.

For any additional information, please contact:

WestCare Adolescent Services

(559) 584-8100 or adolescents.ca@westcare.com
Full Name of Youth:*

First NameMiddle NameLast Name
Parent / Guardian Name:*

First NameMiddle NameLast Name
Date of Birth?*
mm/dd/yyyy
Gender That Youth Identifies As:
Address*

Street Address

Street Address (Line 2)

CityState / Province

Postal / Zip CodeCountry
Phone Number of Referral Source*

Area CodePhone Number
Phone Number of Youth

Area CodePhone Number
E-mail of Referral Source*
Ex. name123@gmail.com
School Attended*
(If applicable)
Referred By:*

SelfParentProbationChild Protective ServicesSchoolOther
How did you hear about us? *
Reason for seeking a substance abuse evaluation?*
Brief description of 1- 4 sentences
By submitting this referral, I confrm that all information is true and complete.
Signature*
Date*

MonthDayYear
Date
Thank you for contacting us. A staff member will be reaching out shortly.
Should be Empty:

Adolescent Services Referral Form