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Behavioral Health Referral Form

Captures the referred individual's details, the referral source, and the clinical background so a behavioral health provider can process the intake smoothly.

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Section

Name

First Name

Last Name

Phone Number

Section

Name

First Name

Last Name

Date of Birth

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Is the Individual aware of this Referral?

Yes No

Type of Services Needed

Outpatient Counseling Inpatient Treatment Case Management Psychiatric Evaluation

Program Needed

Adult Program Adolescent Program Child Program Family Program

School Name

Parent/Guardian Name

First Name

Last Name

Phone Number

Specify service Individual is considering (Adult)

Outpatient Therapy Intensive Outpatient Program Residential Treatment Psychiatric Evaluation

Individual Gender

Male Female Other

Individual Primary Language

English Spanish Portuguese Other

Reason for Referral

Current Medications

Select all applicable challenges for the Individual referred

Anxiety Depression Substance Use Behavioral Issues Trauma Other

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