Behavioral/Mental Health Referral Form

Phone Number:(Required)

Enter area code and phone number with no spaces, dashes, or parenthesis example 4041239876

Preferred Contact Method:

Supervisor Phone Number:

Date of Birth:(Required)

County of Residence:(Required)

Current Insurance Information

Client's School:(Required)

Current Grade Level:(Required)

Social Security Number

Name of Insurer:

*Required if "Other" is selected above.

Policy Number:

Separate multiple entries with a comma.

Mental Health Diagnosis:

Brief Description of Presenting Issues:(Required)

Email Address:

Must be in name@example.com format

Phone Number:(Required)

Probation Officer Name:

Probation Officer Phone Number:

Case Worker Phone Number:

* If client is in the custody of DFCS, please complete this consent form. Type the correct information in the parenthesis.

Please attach any psychological/psychiatric or other supporting documentation.

Max. file size: 256 MB.