Referral Form

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

NOTE: School-based referrals MUST have Medicaid as an insurance option.


Referral Source



Client Info



Legal Guardian Info



Insurance Info



Reasons for Referral




(limit 300 characters)




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.