Online Referral Form

Insurance/Medicaid Clinical Services:

Please complete referral form  in its entirety for therapeutic referrals reimbursed through Medicaid/CMO or Insurance/Self Pay. Once your referral has been reviewed, a representative from our agency will contact you by phone or email to notify you of the intake status.  If you are a client in crisis (or are an agency referring a client in crisis) and in need of immediate services, please provide that information on the referral and you will be contacted immediately.

Please note that we do not provide emergency treatment or emergency stabilization; if there is a risk of self-harm or harm to others, and such intervention is required, please contact your nearest emergency room, or dial 911.