Patient Referral Form for Healthcare Providers or Community Organizations

If you want to refer someone who is in crisis, please do not use this form. Instead, please call our Mobile Crisis Team at 1.866.437.1821 24 hours a day / 7 days a week.


If you work for a healthcare provider or other community organization and you wish to refer a child or adolescent (21 or younger) for one of our other services, please provide the information below.

If you have medical records or other documents to share, please drag and drop them here or use the "browse files" link below.

Drag and drop files here or