Florida Behavioral Health Services Referral Form

NYAP Florida Behavioral Health Services

Referral Form
Referral Source Contact Name*

First NameLast Name
Phone Number

Area CodePhone Number
Referral Agency
Doctor's office, county department, self, 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?*
At this time we are only able to serve these counties. If your county is NOT listed, please call 211 or contact your local child services office for additional assistance.
What concerns are you hoping to address with NYAP Behavioral Health services?*
What type of services you are interested in?

Diagnostic AssessmentIndividual TherapyFamily TherapyIndividual Behavioral AssistanceTrauma-focused Cognitive Behavioral TreatmentI 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.
Should be Empty:

NYAP Florida Behavioral Health Services

Click Submit Below to Complete