Referral form for mental health services 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Referral' at the top of the form. This helps track when the referral was made.
3. Fill in the 'Demographic Information' section, including the youth's name, contact details, gender, date of birth, and address. Ensure accuracy as this information is crucial for service coordination.
4. Complete the 'Parent/Legal Guardian' section if applicable. Include their contact information and relationship to the youth.
5. Indicate the youth's ethnicity/race and primary language. If interpreter services are needed, check 'Yes' and specify any special accommodations required.
6. In the 'Behavioral Health Diagnosis' section, provide details about any diagnoses made by a professional along with relevant medical diagnoses impacting behavioral health.
7. Describe the reason for referral clearly in the designated field to ensure appropriate services are provided.
8. Finally, review all sections for completeness and accuracy before signing off on the release of information at the bottom of the form.

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