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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.