Outpatient Mental Health Referral Form

    • Referral Source Information

    • Client Information

    • Parent or Legal Guardian Information

    • Please answer the following:

    • (In your own words, describe the need for behavioral health services. Please list current behaviors and/or symptoms that the child/adult are exhibiting. Be sure to note any current and/or history of diagnoses, recent hospitalizations, suicidal ideation/attempts/self-harm, interest in psychiatric and medication management services and any other pertinent information necessary for treatment.)

    • If Other, please indicate:

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