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Parent/Guardian Referral Form

You will need to submit the following information in order to complete the referral form:

  • Psychological evaluation dated within the last two years
  • Psychiatric evaluation dated within the last 60 days
  • Psychosocial/Social History/Family Assessment
  • Medical Evaluation/History & Physical with additional information required if the child has a major medical problem
  • Recommendation letter from current physician/provider
  • IEP (if special ed)
  • Current medical insurance card
  • Release of Information. To be legal, it must be completed entirety and must contain 2 signatures (parent/guardian or youth and a witness).

Please contact your mental health professional if you need help with this information. You should have these documents ready to upload before proceeding.




Find mental and behavioral health resources in your state here.

About Us
Youth Villages is a private nonprofit organization dedicated to helping emotionally and behaviorally troubled children and their families live successfully. We help more than 22,000 children and families each year from across the country. Our Evidentiary Family Restoration® approach involves intensive work with the child and family, a focus on measuring outcomes, keeping children in the community whenever safely possible, and providing accountability to families and funders. The EFR approach produces lasting success for children with success rates twice that of traditional services at one-third the cost of traditional care.
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