Referral Form

Outpatient Referral Form

To make a referral for Outpatient services, please fill out the form below, and click the Send button.


(If DA has been completed less than 6 months ago, please fax or email a copy to us.)
Please inform parents to bring the following documents to first appointment:
  • Insurance Card(s); primary, secondary and tertiary insurance cards
  • Client’s Social Security Card
  • Parent’s Drivers License
An email confirmation will be sent to you once an appointment has been made.
Instruct parent to call to schedule an appointment, a follow-up call will be made if contact has not been made within a week of receipt of referral.

**If you would like treatment updates on referred client, please provide: