Client Referrals




Refer a client to our services by filling out the form below. Or, click here to download, print and send manually. For providers only.

Client Information


Parent or Legal Guardian Information


Payment Information


Referral Source Information: Complete this section so we can contact you after the referral is made.

Child/Adult Mental Health Information
Current medication & dosage
Current DSM-IV Diagnosis

Current Mental Health Symptoms
* describe symptom below

Hallucinations *
Delusions
Thought disorder
Bizarre (psychotic) behavior *
Anxiety / Nervousness
Obsessive / compulsive
Phobias / fears
Depressed mood
Mood Swings
Sleep disturbance
Irritability
Anger / temper tantrums
Hyperactivity
Attention deficit
Eating problems
Elimination problems
Oppositional / defiant to those in authority
Antisocial / delinquent behavior / conduct disorder
Over sexualized behavior
Somatic complaints with no known medical cause
Attachment disorder *
Other *

Reason for referral for treatment

In your own words, describe the child/adult in need for mental health services. Please describe specific behaviors the child/adult is exhibiting.