communityempowermentservices.com

Referring Organization / Practice Name

Referrer Name

Professional Role / Title

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Method of Contact

Permission to Contact Referrer

Client Name

First NameLast Name

Client Date of Birth

Date

Client Age Range

Client Gender

Reason for Referral

Please provide a brief description of the concerns prompting this referral

Insurance Provider, if known

Client Contact Information

Requested Service Type

Preferred Location(s)

Has the client / family consented to this referral?

How did you hear about us?

Non-Emergency Use Only

This referral form is intended for non-emergency outpatient mental health services only. Community Empowerment Services does not provide crisis intervention or emergency services through this form.

If the client is experiencing an emergency, is at imminent risk of harm to themselves or others, or requires immediate assistance, do not submit this form. Please contact 911, go to the nearest emergency department, or call the 988 Suicide & Crisis Lifeline for immediate support.

Submission of this referral does not guarantee immediate services. All referrals are reviewed by our administrative and clinical team, and follow-up will occur as availability allows.

Referral Form

Referrer Information

Client Information

Service Preferences