Online Referral
*mandatory field
Name
*
First Name
Last Name
Email
*
Confirmation Email
[email protected]
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REFERRAL SOURCE
(if other than self-referral or caregiver referral)
Date
-
Month
-
Day
Year
Date
Name
*
Agency
Title
*
Phone Number
*
Please enter a valid phone number.
Fax #
Email
*
[email protected]
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CLIENT INFORMATION
(please confirm correct name spelling and DOB with client and/or guardian)
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex Assigned at Birth
*
Please Select
Please select
Female
Male
Intersex
Not designated on birth certificate
Gender Identity
*
Please Select
Please select
Female
Male
Transgender female/Transgender feminine
Transgender male/Transgender masculine
Two-spirit/Genderqueer/Genderfluid
Non-binary/gender non-conforming
Other
Sexual Orientation
*
Please Select
Please select
Straight
Lesbian
Gay
Bisexual
Pansexual
Queer
Asexual
Questioning
Pronouns
*
Please Select
She/her/hers
He/Him/His
They/Them/Theirs
Ze/Hir
Social Security#
*
Insurance
Insurance ID
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
[email protected]
Name of School
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Caregiver #1- If applicable
(If client is a minor)- If not applicable please skip
Relationship to Minor
Preferred Language
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
[email protected]
Caregiver #2
Relationship to Minor
Preferred Language
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
[email protected]
Do the caregivers have full custodial rights to make medical and educational decisions for this child?
Yes
No
Is there another parent or caregiver with joint custody we should inform about treatment?
Yes
No
Does the client have thoughts of self-harm or of harming others?
Yes
No
Does the client have an urgent or critical medical condition?
Yes
No
Does the clienthave a safety threat?
Yes
No
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Reason for Referral
All fields are required
Requested Services
*
Counseling
Medication Management
Diagnostic/Assessment
Group
Crisis/IFI Service
Substance Use
EMDR
Other
A brief summary will expedite assignment to a clinician
*
How did you hear about us
*
Submit
Should be Empty: