Youth Mental Health Referral Form



Please complete this form to initiate a referral for assistance with access to mental health services through OCHN's provider network and/or system coordination for young people, who are justice involved or who face adjudication.




Crisis services are available 24 / 7 - 365:

Common Ground at 800-231-1127 and New Oakland at 877-800-1650

Individual's information

Phone

Referral Source's Contact Information

Phone
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Additional Information

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Please attach any supporting documentation.

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