PeerHive: Make a Referral
Use this form to refer a client to any PeerHive program. We'll contact the client or their guardian to schedule an assessment. Please don't include diagnoses or other clinical details; we'll collect those securely. For emergencies, call 911 or 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
Refugee or immigrant services
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 PeerHive program are you referring to?
*
Please Select
Outpatient Therapy
Community-Based Services
School-Based Services
Not sure/Please advise
Preferred language
Interpreter needed?
Yes
No
Visit preference
In person
Telehealth
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 PeerHive.
*
I agree
Send referral
Should be Empty: