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Referral Form

County
How did you hear about us?
How often would you like a progress report?
Program/Service you are referring to
Payor Source
Is this a DoHS Referral?

Please select YES if your referral is a DoHS or CPS-involved client.

County of Record

Details on client(s) being referred

Would you like to refer another client at this time?

What happens next

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  1. Submit the Referral
    Complete our secure referral form with the participant’s contact information and the services being requested.
     

  2. We Make Contact
    Our team reaches out to the participant, answers questions and schedules an initial telehealth appointment.
     

  3. Assessment and Placement
    We identify the most appropriate service and help the participant begin the recommended program.
     

  4. Updates and Support
    With the proper consent, referral partners receive timely updates regarding attendance, participation and completion.
     

Questions?
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