Referral | Lee Carlson Center for Mental Health and Well-Being

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?

Clinic-Based Therapy

In-Home Therapy Youth

In-Home Therapy Adult - ARMHS

School Based Mental Health

Intensive Treatment in Foster Care

Group Therapy

Psychiatry & Medication Management

Psychological Testing

Domestic Abuse Program

Bridgeview Drop-In Center

CSP/Housing Support Services

Play Therapy

Does the referred client have insurance?

Yes

No

I don't know

Referred Client's Age

Referred Client's Gender

Referred Client's Race

Reason for Referral