Behavioral Health Referral Form
Information about Person Completing Referral
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Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Individual Information
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Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
1
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Individual aware of this Referral?
Yes
No
Type of Services Needed
Adult
Child
Adolescent
Youth to Young Transition
Program Needed
Mental Health Clubhouse
Apex School Based
System of Care
Child/Adolescent Outpatient Services
COVID 19 Intervention Program
Youth to Young Adult Transition
None
School Name
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Specify service Individual is considering (Adult)
Case Management (CM)
Family Therapy (Mental Health ONLY)
Group Therapy (Mental Health ONLY)
Individual Therapy (Mental Health ONLY)
Intensive Case Management (ICM)
Medication Case Management
Peer Supports
Psychosocial Rehabilitation (PSR)
Psychosocial Rehabilitation - Individual (PSRI)
Psychiatric Treatment (needs secondary service)
Supported Employment (Mental Health ONLY)**
Substance Use services
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Reason for Referral
Current Medications
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Submit
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