• Referral

    All Locations: 1(800)304-HOPE (4673)
  • In order to process your referral in a timely manner, please complete as much as possible.

    Consumer Identifying Information

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    Pick a Date
  • Referral Source Information

  • Insurance/Paysource

  •  - -
    Pick a Date
  • Parental Rigths/Guardianship

    The right to consent to treatment for children is exercised by the child/children's parent, guardian, or person who has that right assigned to them by a court of law. The following information is needed to determine the individual to consent to this child's treatment at Tri-County Mental Health Dervices.

  • Requested Services

  • If an Interpreter is needed, complete below:

  • Assertive Community Treatment (ACT)/Community Rehabilitation Services CRS Screening

    Additional required information to process for ACT and CRS

    Mental Health Diagnosis

    In the last two years:

  • Should be Empty: