Behavioral Health Referral Form
Refer yourself, your child, a family member, or a client. Takes about 3 minutes. Our intake team will call within 1 to 2 business days. This form is not monitored 24/7: in an emergency, call 911 or call/text 988. Your information is confidential and protected under HIPAA. Privacy Notice: https://www.dbhhc.org/privacy/
Which Dabney office is this referral for?
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Illinois (Chicago)
California (Lancaster)
1. About you
Who is filling out this form?
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I'm referring myself
I'm a parent or guardian referring my child
I'm a professional (school, hospital, agency, doctor)
I'm a family member or friend
Your name
First Name
Last Name
Your organization and role
Your phone number
-
Area Code
Phone Number
Your email
How did you hear about us?
Ada S McKinley
Insurance
IMAN
DCFS
Riveredge Hospital
Hospital ER
SASS
Garfield Park
Other
2. The person who needs services
Full name of the person who needs services
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First Name
Last Name
Their date of birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Is this for an adult, a child, or an adolescent (teen)?
*
Adult
Child
Adolescent
Parent/guardian name
First Name
Last Name
Relationship
Parent/guardian phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/guardian email
example@example.com
School name
Best phone number to reach them (or their family)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Their email (if they have one)
example@example.com
Their home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Non-binary
Other
Primary language
English
Spanish
Other
If another language, which one?
Does the person (or their parent/guardian) know about this referral?
Yes
No
3. Insurance
Insurance
*
Blue Cross Community Option
Blue Cross PPO
Aetna
Cigna
County Care
United Healthcare
Straight Medicaid
Medicare
Member ID / Medicaid number (on the insurance card)
Group number (on the insurance card, if any)
4. What kind of help is needed?
Which services are they interested in? (check all that apply)
Individual Therapy
Family Therapy
Pathways Program
Couples Therapy
Community Support
Mental Health Consulting Services
Other
What challenges are they having? (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing in Stability
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Nutritional
Phobia/s
Hospital Discharge/Collaboration Planning
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
PTSD Assessment
Sexual Disfunction
Pornography Addiction Assessment
Life Skills Assessment
Other
Reason for the referral, in a few sentences
*
Submit
Individual Information
Specify service Individual is considering
Individual Therapy
Family Therapy
Pathways Program
Couples Therapy
Community Support
Mental Health Consulting Services
Other
Should be Empty: