West Virginia Behavioral Health Services Referral Form

NYAP West Virginia Behavioral Health Services

Referral Form
Referral Source Contact Name*

First NameLast Name
Referral Agency
Doctor's office, county department, etc.
Referral's Contact Email*
example@example.com
Are you referring for yourself or on behalf of someone else?*

MyselfMy Child/YouthOther
Name of person seeking services*

First NameLast Name
Date of Birth*

MonthDayYear
Date
If you are referring on behalf of a youth, what is their Parent or Caregiver's name and relation?

First NameLast NameRelationship
Your email or the Caregiver's Email*
example@example.com
Your Phone Number or Caregiver's Phone Number*

Area CodePhone Number
Address of person seeking services

Street Address

Street Address 2

CityState

Zip Code
What is the person's County of Residence?*
What concerns are you hoping to address with NYAP Behavioral Health services?*
What type of services you are interested in?

Diagnostic AssessmentIndividual TherapyFamily TherapyGroup TherapyCommunity SupportIndividual Behavioral AssistancePsychiatric ServicesMedication Evaluations/Management/Behavioral AssistanceSpecialized Therapy Services for Sexually Reactive YouthTrauma-Focused Cognitive Behavioral TreatmentFunctional Family Therapy (FFT)Strengthening Families ProgramParent-Child Interaction Therapy (PCIT)Eye Movement Desensitization and Reprocessing (EMDR)Play TherapyAlcohol and Drug AssessmentAlcohol and Drug TherapyDrug ScreensI am unsureOther
How did you hear about NYAP?*

Social MediaGoogle SearchWebsiteParticipant of Other NYAP Program(s)Friend ReferralOther
Please verify that you are human*
Click Submit Below to Complete

Once completed, your referral will be processed by the NYAP office nearest you. Most referrals will be processed and contacted within 2 BUSINESS DAYS.
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NYAP West Virginia Behavioral Health Services

Click Submit Below to Complete