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Referral

Referral

*For the ARMHS referral form, please click here

Web Site

Referent's Information

Referent First Name *

Referent Last Name *

Referent Phone # *

Referent Email Address

Referent Title/Role

Referent Organization Affiliation (if any)

Referred Client's Information

Referred Client's First Name *

Referred Client's Last Name *

Referred Client's Phone Number *

My Relationship to the person being referred is: *

Self

My Child

My Family Member

My Patient

Which programs might the referred client be interested in? (Pick Top Three)

Clinic-Based Therapy

In-Home Individual Therapy- Youth (Ages 2-17)

In-Home Therapy Adult - ARMHS

Children's Therapeutic Services & Supports- CTSS (Medical Diagnosis Required)

School Based Mental Health (SLMH)

Intensive Treatment in Foster Care (ITFC)

Group Therapy

Psychiatry & Medication Management

Psychological Testing

Domestic Abuse Program- Aggressor/ Survivor

Bridgeview Drop-In Center

CSP/Housing Support Services

Play Therapy

Does the referred client have insurance? *

Yes

I don't know

Insurance Type (If none or unknown, type N/A) *

Referred Client's Age *

Referred Client's Gender

Referred Client's Race

Reason for Referral *

You should hear back from us within 24 hours or less. If you don’t, please call 763.780.3036.

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First Name *

Last Name *

Email *

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Lee Carlson Center | 763.780.3036

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