New Client Referrals We are currently accepting new client referrals. Referral Form Please complete as thoroughly as possible. All fields marked * are required. Person Submitting ReferralFirst Name *Last NameEmail Address *Phone *Person Being ReferredFirst Name *Last NameParent or Legal Guardian (if under 18)Email of Person Being Referred *Phone Number *Reason for ReferralCheckboxSymptoms of DepressionAnxiety/WorryTrauma/PTSDAngerGrief/LossStressRelationship/Family ConflictBehavioral/Emotional RegulationADHDImpaired SleepImpaired FocusSelf-Esteem/IdentityMedication ManagementIOPCrisis ManagementLife Adjustment DifficultiesCase ManagementResource OutreachInsurance Carrier / Medicaid NumberOther Reasons / DescriptionAdditional InformationIs Summit County Children's Services (SCCS) involved?YesNoHow did you hear about us?Select an optionReferral from provider / doctorSchool or educational programOnline searchSocial mediaCommunity organizationFamily or friendOtherQuestions for our team?Consent *I confirm that I have consent to share this contact information and I agree to the Terms & Conditions.Consent * I confirm that I am 18 years of age or older, or I am the legal guardian of the person being referred. Submit Referral Form
