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. Fairfield County ADAMH Crisis Brochure.

Person completing referral form

First

Last

Referral Source Agency (if applicable)

Email for person completing the form

Referral Source Phone Number

Client's Name

First

Last

Guardian's Name (if applicable)

First

Last

Client/Guardian Phone Number

Client's Date of Birth

Client's Address

Apt, suite, etc.

Country

City

State

Zip code

Payment Method or Insurance Provider

Preferred Office

Services Requested

Diagnostic Assessment for Treatment (includes treatment plan, no formal report)

Counseling

Case Management Services

Therapeutic Behavioral Services

General Psychological Evaluation (includes report writing fee)

Focal Evaluation (includes report writing fee)

Reason for Seeking Services

Does the client/client\'s guardian know that you are making this referral?

Scheduling Conflicts/Restraints

Do you require any special accommodations?

Policy Agreement *

I have read and agree to the Privacy Policy and the Terms and Conditions .

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