Referral Form

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

Referral Source

Client Info

Legal Guardian Info

Insurance Info

Reasons for Referral

(limit 300 characters)

Other Info

(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.