Bright Path: Make a Referral
Use this form to refer a client to any Bright Path program. We'll contact the client or their guardian to set up a first visit. Please don't include diagnoses or other clinical details; we'll collect those securely. If this is an emergency, call 911. If the client is in crisis, they can call or text 988.
About you
Referring Organization Name
*
Referring Contact Person Name
*
First Name
Last Name
Your role or title
Organization type
*
Please Select
Behavioral health organization
Hospital or treatment center
School or youth organization
Community resource center
Social services agency
Court or justice system
Other
Referring Contact Email
*
example@example.com
Referring Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
About the client
Client Full Name
*
First Name
Last Name
Client's age group
*
Under 18
18 or older
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Name (if client is under 18)
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which Bright Path program are you referring to?
*
Please Select
Outpatient Treatment (therapy)
Intensive Outpatient (adults)
Day Treatment (children and teens)
Case Management
Medication support (teens and adults)
Psychological assessment or evaluation
Not sure / please advise
Preferred language
Interpreter needed?
Yes
No
Visit preference
Telehealth
In our office (by appointment)
No preference
Best days and times to reach the client
The client (or their parent or guardian) knows about this referral and agrees to be contacted by Bright Path.
*
I agree
Send referral
Should be Empty: