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Behavioral Health Referral Form

Services Requested
Outpatient Therapy (OP)
Therapeutic Mentoring (TM)
Both Services
Who Is Making The Referral?
Parent/Guardian
Self-Referral
Mental Health Provider
School Representative
Community Agency
Other
Client Information
Date of Birth
Month
Day
Year
Client Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Decline to Specify
Client Gender
Female
Male
Decline to Specify
Other
Client Race
Is the Client Under 18?
Yes
No
Other
Parent/Guardian Information
Relationship to Client

Select Relationship

Insurance Information
Clinical & Referral Information
Has the client previously received behavioral health services?
Yes
No
Unknown
Does the client have any known mental health or behavioral health diagnoses?
Yes - The client has 1 or more known diagnoses
No
Unknown
Is the client currently taking medications?
Yes
No
Unknown
Supporting Documents

Acknowledgement

Submitting a referral does not gurantee acceptance into services. This form is not intended for emergencies.
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