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.