Mental Health Referral Form
Information about Person Completing Referral
Name
First Name
Last Name
Relationship to client
Email
example@example.com
Phone Number
Please enter a valid phone number.
Individual Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Individual aware of this Referral?
Yes
No
Please indicate the type of insurance that patient holds, if any (if Medicaid, please specify - Aetna, Passport, etc.)
Medicaid ID (if you do not know, you can forward to us later via text or email)
Type of Services Needed (check all that apply)
Child Outpatient Therapy (ages 4-12)
Adolescent Outpatient Therapy (ages 13-19)
Adult-ish Class (basic life skills, social emotional learning, etc)
Case Management (housing, food, school help, clothing, job exploration)
Peer Support Specialist
Summer program
Parenting education
Other
School Name
Parent/Guardian Name, if different from person making referral
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Reason for Referral
List allergies, if applicable
Current Medications (if known or applicable)
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Family Conflict
Other
Submit
Should be Empty: