Referrals

Refer a Child toOur Care

Learn about our referral process and how we can help children in need.

Who Can Refer

Referral Sources

We are ready to partner with you. As a caregiver, we know your member's health is your top priority.

DSS (Social Services)

County social services departments

Hospitals

Hospital discharge planners

MCO Care Coordinators

Managed care organization staff

Families

Parents and guardians directly

Schools

School counselors and staff

Healthcare Providers

Physicians and therapists

How It Works

Referral Process

Initial Contact

Reach out to us via phone or our contact form to discuss the childs needs.

Assessment

We review the childs information to ensure we can meet their care requirements.

Tour & Meeting

Visit our facilities and meet with our team to learn about our programs.

Admission

Complete necessary paperwork and coordinate a smooth transition.

Start a Referral

Submit a Referral

Online Referral Form

Complete the form below to refer a child to our services, or download the printable referral form to submit by hand.

Download Printable Form

Referral Source

Name of Person Referring (if not parent)

Agency / Organization

Phone Number of Referral Source

Source of Funds

Service(s) and Level of Care Requested

Date of Referral

Client Information

Client First Name, Middle Initial, Last Name *

Home Address

City

Zip

Primary Phone

Secondary Phone / Email

Client Gender

Client Race

Client DOB

Client Age

Client Grade Level

Primary Language

Client Previous School

Parent / Legal Guardian Information

Legal Guardian Name

Relation to Client

Mailing Address (if different)

City

Zip

Legal Guardian Phone (if different)

Clinical Information

Presenting Problem / Reason for Placement

Diagnosis

Medication

When Is Service(s) Needed

Please be prepared to provide a psychiatric evaluation, CCA, ISP/BSP, and any other relevant documents. Our team will request these after your referral is received.

Ready to Learn More?

(704) 606-9243