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Mental Health Services Referral Form

Standard referral form for all MH services.
  • Client Information

  • MM slash DD slash YYYY
  • for insurance verification
  • Minor Guardian & Contact Details

  • Please enter primary guardian(s) first. Include all parties with guardianship or custody status.
    NameRelationshipCustody StatusPhone Number 
  • Referent Information

  • Insurance/Payer Information

  • Services Needs & Primary Concerns

  • Check all that apply
  • Check all that apply
  • Examples include specific gender, Spanish-speaking, African-American or Hmong, etc.
  • Please indicate a specific therapist's name or you cultural/language preferences here.
  • Safety Concerns

  • Additional Information & File Upload

  • Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client.
  • Upload any DA, release of information, court/CPS records, or other pertinent information
    Drop files here or
    Max. file size: 32 MB.

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    • About Us
      • Contact
        • Staff
        • Staff Links
      • Katy’s Story
      • Our Staff
    • Programs & Services
      • Zoom Teletherapy Info & Links
      • Therapy
      • Roots Recovery
        • Roots Recovery Home
        • Roots Client Forms
      • ARMHS Services
      • CTSS Services
      • Parent Community Support Program
      • Digital Navigation Services
    • Referrals/Intake
      • Electronic Forms Library
      • Make a Referral to Mental Health Services
      • Make a Referral to Roots Recovery
      • Mental Health Intake Forms
      • Internal Referrals
    • Trainings
      • Upcoming Trainings
      • Virtual Trainings
      • Your Training Account
      • Login to Training Portal
    • Careers