Referral for Services Form

 

Please complete the below referral for service form. If you are submitting on the behalf of a potential client, please obtain client/guardian’s consent prior to completing the referral. Please note that the information will be submitted electronically and may not be secured. Once your submission has been received, a staff member will be in contact within two business days. For further information about the services we offer please refer to our Services page.

In the event of an emergency or need to speak with a clinician immediately, please visit your nearest emergency department or Netcare Access (http://www.netcareaccess.org/).  If you are experiencing a crisis or have an urgent need, please contact National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).  Additionally, there is a Crisis Text Line that serves anyone in any type of crisis.  It is available by texting “HOME” TO 741-741.

Referral for Services Form

 
 

Verification