Main Agency Referral Form
Please do not use this form for emergencies. For mental health emergencies, please call 211.
Please note that some information, like client or referral name, may be asked more than once, and more information and documentation may be required depending on the service you requested. A contact number is also required.
Referring Agency Information
Date of Referral:Settings
*
-
Month
-
Day
Year
Date Picker Icon
Referral Source:
*
Please Select
Hospital/Behavioral Health
Self
Law Enforcement
School
DCF/CCKids/CHS
Family
Medical or Psychiatric Practice
Court/Legal
Other
Other Referral Source:
Service(s) Requested:
*
Please Select
Psychiatric Services
Adult or Child Individual Therapy
Targeted/Intensive Case Management/PSR
Children's Care Coordination
Children's Case Management
Substance Abuse Services
Adult Care Coordination
Name of Referring Agency or Provider:
e.g., hospital's name, doctor's name, DOC, etc.
Other Service Requested:
Referring Party's Name:
First Name
Last Name
Received via SFax
Yes
Referring Party's Contact Number:
*
Please enter a valid phone number.
Referring Party's Email Address:
example@example.com
Client Information
Client's Name (name of person you are referring for services):
*
First Name
Last Name
Client's City of Residence:
Client's County of Residence:
Client's Age Group:
*
Please Select
Adult (18 >)
Child (< 18)
Client's Contact Number (contact number for the person you are referring for services):
Please enter a valid phone number.
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File Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Accepted for Services
Please Select
Yes
No
Complete:
Please Select
Yes
No
Medical Record #
Internal Referral Click Here
Comments
Internal Contact Info:
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Depending on the service you've selected, clicking Submit may direct you to another form.
Submit
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